Private insurer Optum issued a laboratory benefit management program that imposes limits on the number of CPT code 88305 units that will be reimbursed by specimen type. The program will automatically deny reimbursement for what are deemed inappropriate add-on tests.
Optum announced this policy change in a press release on June 22, 2022. The insurer says the program was designed to “reduce unnecessary lab testing” and to save health plans an estimated $3 billion annually. In collaboration with other organizations, the insurer claims the program follows clinical guidelines for determining reimbursement of testing. Furthermore, Optum indicates that comprehensive test policies and prior authorization services along with unique genetic test identification are intended to assist physicians in ordering the correct tests and to optimize utilization management.
The College of American Pathologists (CAP) wrote in a June 2 letter to Optum that it is opposed to this policy for the risks it poses to patients, providers, and the entire health care system. The CAP argues that this restrictive policy overlooks the lack of control that pathologists and clinical laboratories have over the number of specimens sent to them. Additionally, the CAP accused Optum of lacking transparency in sharing the clinical guidelines it utilized to develop the policy with regard to how laboratory claims are evaluated. Finally, the CAP called for additional details on the appeals and processes related to the policy.
The CAP has requested a meeting with Optum to further advocate for its position on this policy and to provide common clinical examples of when billing for more 88305 codes is necessary.
Sources:
https://documents.cap.org/documents/optum-cap-letter-2023.pdf
https://www.cap.org/advocacy/latest-news-and-practice-data/june-27-2023#story2
https://www.optum.com/business/health-plans/care-management-costs/laboratory-benefit-management.html
