Updates to Provider Manual Affect Laboratory Results Data Sharing and Provider Reimbursement

As you may know, Humana recently updated its Provider Manual, and the revised version is effective Oct. 21, 2013. One of the updates pertains to the submission of lab results data to Humana and the potential impact to provider reimbursements. There are several important points for Humana network health care providers to understand.

  • As always, Humana's objective is to comply with NCQA and CMS requirements and to work with health care providers to support the overall well-being of our members: To that end, we must work together with network health care providers to capture and submit member data to report on HEDIS and Stars, as well as other quality-related activities. The HIPAA Privacy Rule permits a provider to disclose protected health information to a health plan for the quality-related health care operations of the health plan, provided that the health plan has or had a relationship with the individual who is the subject of the information. Additional details can be found on the following website: http://www.hhs.gov/ocr/privacy/hipaa/faq/disclosures/265.html.
  • To the extent providers utilize them, Humana will leverage national reference labs when possible to obtain lab results data: Humana can capture Humana member lab results data through existing connections with national reference labs, such as Laboratory Corporation of America or Quest Diagnostics®. As such, Humana may not need to gather lab results directly from your practice. In situations where automation is not available in the provider's office, Humana may contact the provider to arrange for an on-site visit to the provider's office to retrieve the lab results from the provider's office.
  • Providers should continue business as usual until contacted by Humana: Humana's goals are to capture the lab results with minimal disruption to the provider's operations and to leverage the provider's existing technology to capture those lab results. Humana will work diligently with the provider to identify the best way to capture lab results. The Humana network relations director or contracting representative will contact the provider to initiate that discussion. Keep in mind, payments will not be immediately impacted on the effective date of the revised provider manual; Humana will contact providers before reimbursements are impacted, and it will be outlined in your contract or contract amendment. Please contact your local Humana network relations director or contract representative for further details about your contract. Otherwise, until contacted by Humana, providers need not make any change to what they are doing today.

The lab results data information is located on page 16 of the Provider Manual, which is posted on the Publications page.

Refer to this frequently asked questions and answers document and the FAQs below for more information:

  • Is Humana also defining radiology as a "lab" test? For this initiative, only claims submitted to Humana with a lab-related Current Procedural Terminology (CPT®) code are a part of this requirement.
  • If a patient has a biopsy, is Humana requiring the person doing the procedure to submit the pathology results? For this initiative, the entity being reimbursed is responsible for submitting the results to Humana.
  • Is the insurance company entitled to those results based on the patient's enrollment agreement? The request to obtain this information is a health care operation of Humana to enable quality and population health improvement activities. The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule permits such disclosure between covered entities.
  • What are the ramifications if a patient refuses to have results sent to his or her insurance company? For this initiative, there is no ramification to the patient or the health care provider in such instances.
  • Certain states have particular requirements concerning specific types of medical information, including patients' release of authorization forms. What is Humana's recommendation to physician practices on how to remain compliant with their state and federal laws? In addition, what are some safeguards that Humana has implemented for physician practices that wish to comply with state and federal patient privacy laws, especially as they relate to alcohol and substance abuse, mental illness and HIV/AIDS? Where can this information be located in Humana's Provider Manual? For this initiative, the obligation of a health care provider to comply with more stringent state or federal privacy laws remains the provider's obligation. However, Humana is aware that there may be more restrictive laws and expects providers to fully comply with such laws. Humana will work with providers on a case-by-case basis. There will be no impact to providers for operating within the guidelines of the law.
  • Could payment be delayed if results do not accompany submitted claims? For this initiative, claims payment will not be delayed due to a health care provider's noncompliance with this contractual obligation. A noncompliant provider's reimbursements for lab-related charges may be impacted through reimbursement (payment) recovery following a retrospective audit of claims and lab results stored in Humana's information systems. However, Humana does not intend to impact payment at this time. Further information will be communicated to health care providers before reimbursement reductions occur.
  • With regard to possible delay in payment for [inexpensive] lab tests, what is Humana's recommendation to solo physician practices that lack the automation to send in test results? For this initiative, in instances where automation is not available, Humana may conduct an on-site visit to the health care provider's office to retrieve the lab result from the physician's office. We will work diligently with health care providers to determine the best approach for data submission that works for both parties.
  • With which specific accreditation and regulatory requirements [established by the Centers for Medicare & Medicaid Services (CMS), National Committee for Quality Assurance (NCQA) and/or other regulatory agencies] does Humana have to comply? Humana complies with CMS, NCQA and various states for Healthcare Effectiveness Data and Information Set (HEDIS®). See links below:
  • Is the release of this information considered a violation of privacy under HIPAA and/or the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2008? For this initiative, the provider will need to make the determination if he/she cannot release all lab data due to compliance with HIPAA/HITECH or other state laws that may restrict what can be disclosed. There will be no impact to providers for operating within the guidelines of the law.
  • For what will lab data be used? These data will be used within the guidelines allowed by HIPAA and the Genetic Information Nondiscrimination Act (GINA). These data allow Humana to comply with accreditation and regulatory requirements established by CMS, NCQA and/or other regulatory agencies. Data may also be used to establish member clinical profiles, to more easily predict disease progression sooner and reduce acuity, as well as calculate HEDIS qualitative scores, and other member-related initiatives.

Specific lab data sharing file format information is available here.