Although genomic testing has been around for decades, the number of available tests is growing at an unprecedented rate. There are over 150,000 tests on the market today, and new ones arrive every week. This makes it difficult to keep up with all the changes and know what has clinical utility and in which circumstances.
While many genomic tests offer known benefits, many also have unproven clinical utility; different types of tests are performed for the same indication without clear information describing the differences and their potential effects; different types of tests are Can be billed under the same code, as well as tests with multiple encoding options.
Another challenge is that health care providers (HCPs) and laboratories are often unaware of health plan coverage standards or the process for obtaining prior authorization. Due to a lack of familiarity with the available tests for an indication and how they compare, healthcare providers may end up ordering tests that are not the most clinically appropriate. At the same time, health plans may not have mechanisms to ensure that coverage policies respond to the fast-paced changes in the genomics and testing market, and the plan may not include the latest reimbursement guidelines for genomic testing.
There are also wide differences in the use of program code.about 400 CPT code Can be used to bill for an estimated 150,000 genetic tests on the market today. Due to the lack of specificity in the molecular coding of most 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, resulting in partial reimbursement or denial of claims even though providers believe they have appropriate prior authorization.
Lack of clarity has consequences
If the above barriers are not addressed, there may be repercussions for patients. For example, patients may end up incurring substantial out-of-pocket costs. Additionally, HCPs may hesitate before ordering tests due to reimbursement issues, which may prevent or delay timely access to critical information that can impact patient care and treatment options.
Ambiguity may also lead the HCP to order a test that may not be the most clinically appropriate or for the disease of interest. This leads to increased costs and unnecessary or wasteful tests, which can also negatively impact patient outcomes.
take a holistic approach
To get to the root of existing reimbursement problems, health plans should consider addressing genomics benefit management in a holistic manner to address test ordering and billing challenges.
Two of the many levers that health plans can use to ensure appropriate genomic testing administration involve prior authorization (PA) and payment integrity (PI) plans directed by geneticists. When PA and PI programs work together, they can produce more reliable and predictable results for all members, HCPs, laboratories, and health programs.
1. Review prior authorization
A well-designed prior authorization program for genomic testing can help reduce unnecessary or incorrect genomic testing. Such a plan also ensures that tests ordered by HCPs are compliant with evidence-based health insurance policies.
The program should provide real-time assurance that the required tests are in compliance with current evidence and reimbursement rules. It should also provide HCPs and laboratories with a clear understanding of what health information may be required to obtain prior authorization, as well as the appropriate CPT codes.
Note that creating reliable prior authorization procedures can be complex. In addition to the large number of tests available, health plans often cannot reach staff with deep genomics knowledge and experience to provide valuable guidance on the details of genomic test utilization plans, including which tests are covered and how to respond to new test entry market.
That’s where the benefit of working with a trusted genomics expert comes in. These experts serve as resources to develop prior authorization processes, keep genomic coverage policies up-to-date, and guide providers on the most appropriate test or in-network laboratory selection for a patient’s clinical indication.
2. Review payment integrity
While a solid prior authorization program can help reduce clinically unnecessary genomic testing, it does not address widespread changes in genomic testing billing. A comprehensive payment integrity process can resolve these inconsistencies.
Regular coding reviews can enhance genomic testing identification of claims and address the wide variability in coding submitted by laboratories. Edits can then be applied to align the code with medical policy to prevent inappropriate claims payments. As a routine model emerges, health plans may need to create new editors, enhance existing editors, update their coverage policies, or adjust previous authorization rules.
Genome experts, especially those with molecular coding experience, have unique skills that can be important assets in managing these changes. Coding changes should be regularly monitored and cross-referenced against current practices. A payment integrity process rooted in genomics expertise allows health plans to take a proactive rather than a reactive approach — addressing genomic testing billing practices and spending before they get out of hand.
The right strategy can help ensure more predictable reimbursement
When health plans create and maintain a holistic approach to genomic benefit management that combines PA and PI plans developed under the guidance of genomics experts, they address two common reimbursement challenges: unnecessary genomic testing and inconsistent encoding and billing.
When these genomics-powered PA and PI programs work together, they can help healthcare providers, patients, and laboratories overcome authorization barriers on the front end of the genomic testing process and reimbursement barriers on the back end. By pursuing this strategy, health plans can strengthen their genomic testing programs and ensure that patients get the testing they need when they need it, and that HCPs and laboratories are properly compensated.
Photo: Andy, Getty Images
