As health plans struggle to cope with the rapid growth in genetic testing, they’re finding that their programs for routine test management are not up to the task.
An estimated 180,000 genetic tests are on the market, with an average of 10 new tests added daily. CPT coding has yet to keep up. Only about 500 CPT codes are used for 360 times the number of tests. The resulting system is slow, inefficient, expensive, and prone to waste, fraud, and abuse. Health plans need management programs designed specifically for genetic testing, which will only grow in volume and complexity.
Whether designing their program or partnering with a lab benefits management firm, health plans should be sure the following nine elements are incorporated into their genetic testing benefits framework:
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- Accreditation and regulatory compliance: Utilization management is necessary to ensure patients receive the proper care and required services without overusing resources. Accreditation by respected agencies like the NCQA and URAC and good standing with state regulatory agencies help ensure that organizations making these decisions follow objective, evidence-based best practices and a central tenet of genetic test management.
- Coverage criteria based on science: The volume of genetic tests is exploding, and maintaining a current understanding of the clinical science and the appropriate coverage criteria documented in clinical policies requires a frequent review cycle. To ensure the latest science and clinical medicine are codified in medical policies, experienced working laboratorians, pathologists, and geneticists should perform a comprehensive scientific and clinical review of the newest literature annually or as the science warrants.
- Ongoing evaluation of test quality: Genetic testing must meet appropriate scientific and clinical standards beyond creating and maintaining coverage criteria. Guaranteeing labs have completed sufficient scientific, technical, and clinical validations is essential to ensure the information provided to the clinician meaningfully informs patients’ healthcare needs. Plans should have staffing and systems to ensure labs are being evaluated beyond the credentialing requirements.
- Expedited review of prior authorizations: Prior authorizations can be frustrating and time-consuming for all parties involved. Health plans must ensure that the lab providers receive information detailing coverage criteria to expedite the review process. Using codes from programs like MolDX® is another key to automating prior authorization. Using specific genetic billing codes increases test specificity and directly links the test and policy, allowing automation equivalent to specific CPT codes. The benefits are increased physician satisfaction, faster turnaround time for authorization requests, and lower costs for health plans.
- Enhanced provider education and experience: In many cases, laboratories will perform the same or similar genetic tests while billing with different combinations of CPT codes. Establishing coding requirements for each test at each laboratory would allow streamlined operations and more comparative analytics within the plan. The test specificity concepts discussed provide a clean, robust, and efficient means to overcome potential code challenges and clarify provider billing requirements. Health plans adopting a specificity method for test identification will realize increased operational efficiency, improved laboratory and physician satisfaction, and reduced potential fraudulent billing practices.
- Claim to authorization match during adjudication: In many cases, the criterion for matching allows broad, non-specific matches, which contribute to inappropriate payments, stopped claims for manual review, delays in claims payment, and the potential for fraud. Increasing the flexibility and specificity of matching criteria contributes to alleviating those challenges.
- Ongoing utilization management vs claims adjudication: Plan best practices include a continual evaluation of laboratory tests, required coverage criteria, and historical laboratory performance to determine when a specific laboratory or a collection of tests should be adjudicated during the claims process without prior authorization or continue utilization reviews in a PA process. Additional controls, such as periodic auditing of laboratories to ensure continued compliance, are recommended.
- Prevention of fraud, waste, and abuse: The looser the operating framework for testing, the more likely fraud, waste, and abuse will occur. Integrating test specificity and enhanced claim-to-authorization matching processes will reduce the above, saving plans money.
- Optimized laboratory network: Though the tests they perform might be identical, not all labs operate at the same level. High-performing labs can be identified through quality evaluations, results, and audits. Once the trusted labs have been designated, plans can be promoted to patients, providers, and even tier networks with increased benefits to those who use higher-tier labs. In return, the labs that benefit from promotions can offer plans for unit price reductions.
Genetic testing is going to become a more significant part of healthcare. Plans that establish science-based policies for managing it effectively will be in the best position to realize the maximum benefits for patients, providers, and themselves.
Photo: Lonely…, Getty Images
How Payers Use Tech to Support Healthcare Transformation
Executives at the ViVE Payer Insights event earlier this year discussed prior authorization, AI, value-based care and the role of tech to help achieve their goals.
Jason Bush, Ph.D., is the Executive Vice President of Product for Avalon Healthcare Solutions.
Sarah Bretz is a Product Manager for Avalon Healthcare Solutions, where she is responsible for genetic test management solutions, including GTM, PGTM, and the AvalonSelect Genetic Network.
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