The national blood testing lab Quest Diagnostics has been handing thousands of Southern California Medicare patients with diabetes a "non-coverage" notice that physicians say is provoking patients to reject their essential A1c tests, which federal officials say violates Medicare rules.
"This is a terribly ill-conceived administrative move that was done without consideration of the tremendously negative impact it is having on patient care," says Paul Speckart, MD, a San Diego endocrinologist. When patients in the practice he shares with four other doctors receive this form, "about one-third are canceling the test."
The form, called an "Advance Beneficiary Notice of Noncoverage," or ABN, is a Medicare template intended to warn patients that Medicare imposes limits on coverage. The A1c test, which doctors typically order every 90 days, is covered only once every three months. If more frequent tests are ordered, the beneficiary needs to know his or her obligation to pay the bill, in this case $66 per test.
If providers do not give patients these ABN forms to sign and the claims are denied, the provider is not entitled to collect directly from the patient.
Non-compliant language
However, the version of the form Quest is distributing does not inform patients that Medicare covers the test every three months. The form includes this language that Medicare officials say is problematic:
- "Medicare does not pay for these tests for your condition."
- "Medicare does not pay for these tests as often as this (denied as too frequent)."
- "Medicare does not pay for experimental or research use tests."
- The "estimated cost" is $66.
This form "does not comply with the standards for valid ABN issuance," Medicare's Jennifer Smith, director of the Division of Appeals Policy and Evelyn Blaemire, Senior Health Insurance Specialist, said in an e-mail response to HealthLeaders Media.
The rule specifies that the provider "must clearly indicate on the ABN which portions of the pre-printed information are applicable."
The Quest form has been in place for about two months in a region covering eight Southern California counties, or about 21 million people. Of those, about 13% are Medicare beneficiaries. More than 20% of Medicare beneficiaries are estimated to have diabetes, or about 554,000 people in this area who should receive quarterly A1c tests. Quest is one of two major labs serving this population. The other, LabCorps, does not use these forms, Speckart says.
Doctors 'astounded' at Quest's practice
He became aware of the new Quest practice two months ago—sooner than most doctors—because he sends his patients to a Quest blood draw center down the hall within his building. He heard feedback right away.
"Patients started to mention they didn't get their A1c because the lab had handed them this form saying it wasn't covered. It didn't sound right at all, because it flies in the face of standard medical practice for diabetes care," he says.
He called Quest, whose administrator confirmed Quest's new policy, he says. He and the four other doctors in his building "were astounded."
Speckart says the A1c is the best way clinicians have to assure sufficient levels of blood sugar are maintained or whether insulin dosages should be altered. Failure to monitor quarterly can result in insidious deterioration to vascular and organ systems, such as eye, kidney, nervous system and heart. "Without this, the potential for getting out of control is obvious," he says.
"Clearly, whoever designed this form did not think what the impact would be," he says, adding that doctors who haven't seen this in their patients will just have to wait a few months, when their regular patients return for their quarterly visits without their A1cs.
Additionally, he says some of his patients now ask, "'Why is Dr. Speckart doing this if the government doesn't pay for it?' It probably undermines the confidence they have in us. Because of this, some of our physicians have elected not to use Quest anymore for lab work."
Kim Gotfredson, Quest's Senior Client Liaison for the Los Angeles Metro office, which covers services in San Diego, Orange, Los Angeles, Ventura, Kern, Riverside, San Bernardino, and Imperial counties, explained the new policy to HealthLeaders Media.
Quest: denying testing "is not our practice"
"Sometimes a provider doesn't necessarily know that the patient went somewhere else and had that test done. That's where it gets difficult. That patient may have gone to a specialist at one point, and then to a PCP (primary care provider) at another point, and that communication didn't get back to the specialist," she says.
Has this resulted in some patients walking away without getting the test? "Yes, for some of them that does happen, but not that much. A lot of patients do know this is not going to be an issue because they haven't had the test done for over three months," she said.
Gotfredson agrees that a patient who might see this form could misunderstand and "opt not to have the test done and that's not good patient care. I totally get where ... Dr. Speckart is coming from." Gotfredson said she would take it up with other Quest managers, however she emphasized that patients are not being asked to pay $66 up front.
"It's not that this has been denied, because it hasn't been billed yet," she said.
Quest corporate spokeswoman Wendy Bost in Madison, NJ, said in an e-mail the ABN form Quest issues "is consistent with CMS guidelines, and in fact much of the language in our forms (including the language you have cited in your e-mail below) is verbatim from these guidelines. We are now in contact with CMS."
She added, "Denying clinically appropriate laboratory testing to Medicare beneficiaries serves neither our patients nor our business, and is not our practice."
Bost did not respond to a question about whether the policy is being implemented in other Quest divisions besides Southern California.
Impact on physician performance measures
The impact of Quest's policy has ramifications on physician performance metrics as well. Medicare's Physician Quality Reporting System or PQRI, penalizes reimbursement for doctors with lower percentages of diabetes patients who obtain quarterly A1cs.
The American Association of Clinical Endocrinologists in Jacksonville, FL, had not heard about the Quest's ABN language. But its director of member advocacy, Anita Sumpter, said after seeing the form, "The physicians may need to start informing their patients prior to them going to have blood work done what is an ABN and why Quest is presenting it to them. They may also need to work with Quest to get them to provide a better explanation why they are providing the ABN to the patient.
"Quest has to do their due diligence in appealing denied claims before billing the patient for denied services. They could get into serious trouble with this type of practice because CMS does not recommend routinely providing patients with ABNs."
Speckart says the issue has created enormous headaches for his office, which sees a large share of diabetes patients. Quest's form "has inserted another layer of difficulty in a practice already grappling with an increasing number of regulations," he says.
For Medicare officials Smith and Blaemire, the bottom line is patient care. "When the ABN is issued consistent with Medicare policy, it serves to protect both providers and beneficiaries from unexpected financial liability and should not deter beneficiaries from receiving covered care that is medically reasonable and necessary," they wrote.
They said they "will follow up with Quest to re-educate the provider on the delivery requirements for ABNs." They add, "providers must exercise caution before adding any customizations beyond these guidelines, since such alterations could result in the ABN being invalidated and make the provider (in this case Quest) liable for non-covered charges."