June 17, 2021
As previously reported, the California Medical Association (CMA) has received a number of calls from physician practices about various payors under reimbursing for COVID-19 testing. In February, CMA asked the California Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) to investigate concerns that some health plans and insurers are shifting the financial risk of critical COVID-19 diagnostic testing to physicians by reimbursing at far below the cost of the test itself.
CMA has since learned that UnitedHealthcare recently sent a notice to some pediatric and family medicine physician practices offering to increase reimbursement for COVID-19 diagnostic testing services. The notice, which includes a one-page COVID-19 Diagnostic Testing Rate Amendment, indicates that for dates of service Jan. 1, 2021, through Dec. 31, 2021, UnitedHealthcare will reimburse the following COVID-19 test codes at 100% of the Centers for Medicare and Medicaid Services (CMS) rate for individual exchange, individual and fully insured group market health plans.
UnitedHealthcare has confirmed it issued multiple notices to targeted pediatric and family medicine providers. Pediatric and family medicine practices that wish to discuss increased reimbursement for COVID-19 diagnostic testing and/or begin the verification process can contact UnitedHealthcare at firstname.lastname@example.org or (866) 229-2921.
Despite these reported increases to COVID-19 testing services, CMA remains concerned that UnitedHealthcare is not increasing reimbursement for the COVID-19 rapid antigen test, CPT code 87426. These inexpensive tests are used at the point of care and return a result within approximately 15 minutes. Each rapid antigen test kit costs physicians approximately $35-$40. However, CMA has heard from several physicians that Anthem and UnitedHealthcare have reimbursed at less than half of the physicians’ costs. The underpayment for this and other COVID-19 rapid tests is what prompted CMA to file complaints with both regulators earlier this year.
When payors shift the financial responsibility for COVID-19 testing to physicians, it becomes financially untenable for physicians to utilize the rapid test for their patients. CMA has strongly urged regulators to formally investigate and take appropriate action to ensure payors are not impeding patients’ access to appropriate and necessary COVID-19 testing and profiting at the expense of treating physicians.
Contact: Mark Lane, Director of CMA’s Center for Economic Services, at (888) 401-5911 or email@example.com.