Although genomic testing has been around for decades, the volume of available tests is increasing at an unprecedented rate. There are more than 150,000 tests on the market today, and new ones are arriving weekly. That makes it tough to stay abreast of all the changes and know what has clinical utility and in which scenarios.
While many genomic tests offer known benefits, there are lots of tests with unproven clinical utility; different types of tests for the same indication without clear information describing the differences and their potential impact; different types of tests that all can be billed under the same code and tests with multiple coding options.
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Another challenge is that healthcare providers (HCPs) and laboratories often are not clear about health plan coverage criteria or processes to obtain prior authorization. Due to a lack of familiarity with the available tests for an indication and how they compare, a healthcare provider may end up ordering a test that is not the most clinically appropriate. At the same time, a health plan may not have mechanisms to ensure that coverage policies address fast-paced changes in genomics and the testing market, and the plan may not include reimbursement guidance for the latest genomic tests.
There is also widespread variation in procedural code usage. There are approximately 400 CPT codes available to use in billing for the estimated 150,000 genetic tests on the market today. Due to the lack of specificity in molecular coding for the majority of genomic tests, different laboratories use different codes to bill for similar tests.
As a result, HCPs may not know which code or combination of codes applies to which test, leading to partial reimbursement or a claim denial, even when the provider thinks they have obtained the appropriate prior authorization.
A lack of clarity has consequences
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If the above mentioned hurdles aren’t addressed, there can be ramifications for the patient. For example, patients may end up with significant out-of-pocket costs. In addition, HCPs may hesitate before ordering a test because of reimbursement concerns, which could prevent or delay timely access to critical information, impacting patient care and treatment options.
Ambiguity may also cause the HCP to order a test that might not be the most clinically appropriate or targeted to address the condition of concern. This results in increasing costs and unnecessary or wasteful testing, which can also negatively affect patient outcomes.
Taking a holistic approach
To get to the root of existing reimbursement problems, health plans should consider tackling genomic benefits management in a holistic way that addresses test ordering and billing challenges.
Two of the many levers that health plans can pull to assure appropriate genomic testing management involve prior authorization (PA) and payment integrity (PI) programs guided by genetics experts. When PA and PI programs work together, they can yield more reliable and predictable outcomes for all—members, HCPs, laboratories and health plans.
1. Examining prior authorization
A well-designed prior authorization program for genomic testing can help reduce unnecessary or incorrect genomic testing before it occurs. Such a program can also ensure that tests ordered by HCPs are in line with evidence-based medical coverage policies.
The program should provide real-time assurance that the test requested is in line with the current evidence and reimbursement rules. It should also provide clarity for the HCP and the laboratory as to what health information may be needed to obtain the prior authorization, as well as the appropriate CPT codes.
Note that creating a reliable prior authorization program can be complicated. In addition to the sheer number of available tests, health plans frequently don’t have access to staff with the depth of genomics knowledge and experience to provide valuable guidance on genomic test utilization program specifics, including which tests to cover and how to respond to new tests entering the market.
This is where it’s beneficial to work with trusted genomics professionals. Such experts serve as a resource for developing the prior authorization process, keeping genomic coverage policies current, and guiding providers to the most appropriate test or in-network laboratory option for the patient’s clinical indication.
2. Reviewing payment integrity
Although a solid prior authorization program can help reduce clinically unnecessary genomic testing, it doesn’t tackle the wide variability in genomic test billing. A comprehensive payment integrity process can attend to these inconsistencies.
Regular coding reviews can enhance genomic test identification on claims and address the wide variability of coding submitted by laboratories. Edits can then be applied to align the codes with medical policy to prevent inappropriate claims payments. As regular patterns emerge, the health plan may need to create new edits, enhance existing edits, update its coverage policy or adjust prior authorization rules.
Genomic specialists, especially ones with molecular coding experience, are uniquely skilled and can be a great asset in managing these changes. Coding changes should be monitored routinely and cross-referenced against current practices. A payment integrity process rooted in genomics expertise allows health plans to be proactive instead of reactive—addressing genomic testing billing practices and spending before they spin out of control.
The right strategy can help ensure more predictable reimbursement
When health plans create and maintain a holistic approach to genomic benefits management that integrates both PA and PI programs developed with guidance from genomics specialists, they can address two common reimbursement challenges: unnecessary genomic testing and inconsistent coding and billing.
When these genomics-powered PA and PI programs work together, they can help healthcare providers, patients and laboratories navigate the authorization hurdles on the front-end and reimbursement roadblocks on the back-end of the genomic testing process. By pursuing this strategy, health plans can strengthen their genomic testing programs and make sure that patients get the tests they need when needed, and HCPs and laboratories receive appropriate compensation.
Photo: Andy, Getty Images
Kelly Athman is a board-certified genetic counselor with more than 15 years of experience in the healthcare industry. Her passion about increasing access to genomics care and appropriate testing drives her role as the senior director of medical affairs at InformedDNA. Having worked within a health plan prior to pursuing a career in genomics enables Kelly to bring a unique perspective on the intersection of genomics and benefits management. Prior to joining InformedDNA, she served as a genetic counselor for Fairview Hospitals and Clinics, Children’s Mercy Hospital, and CentraCare Health Systems. Kelly holds an M.S. in Molecular, Cellular, Developmental Biology & Genetics and a B.A. in Psychology and Biology from the University of Minnesota.
