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Understanding Genetic Testing Complexities in Healthcare

Genetic testing was once only available to individuals with a family history of certain genetic conditions or those who were experiencing symptoms. In recent years however, advances in technology have made it easier and more affordable to analyze DNA, making genetic testing more accessible to the general public. And as health plans are constantly looking for novel ways to identify individuals that may benefit from early intervention programs, genetic testing is becoming a powerful tool in this effort to provide more personalized medicine.

As a result of these trends, the volume and complexity of the medical policy, coding, and utilization review surrounding genetic testing has skyrocketed:

  • 150,000+ genetic tests are on the market, compared to 10,000 only 10 years ago
  • 9 codes are billed to represent a single genetic test
  • 1,000+ pages of medical policy for providers and payers to try to interpret

For many payers, processing genetic testing claims is a tedious, manual, and time-consuming process. There are several reasons for this:

  • Complexity of genetic testing: Genetic testing can be complex, and the interpretation of test results may require specialized knowledge and expertise. In some cases, payers may need to consult with genetic counselors or other experts to ensure that claims are processed accurately.
  • Lack of standardization: There is currently no standardized process for genetic testing, which can make it difficult for insurance companies to determine which tests are appropriate and what constitutes a medically necessary test. This can result in delays or denials of claims.
  • Billing codes: The process of billing for genetic testing can also be complicated. Each test may have its own unique billing code, and the correct code must be used to ensure that the claim is processed accurately.

Health plans that rely on outdated approaches are experiencing a growing volume of prior authorizations, denials, reviews, and appeals – all made more complex by multi-gene panel tests with multiple billing codes. The result is waste, variable quality, and frustrated members, providers, and medical directors.

Understanding Genetic Testing in Healthcare: A Better Way Forward

To navigate these challenges and help payers reduce the manual labor and time associated with processing genetic testing claims more accurately, Source has partnered with Concert Genetics, an industry leader in genetic test payment accuracy.

Concert Genetics has developed proprietary content and technology that streamlines clinical policy maintenance, prior authorization, coverage determination and claims processing for genetic testing. Here’s how it works:

  • Payment policies that clarify and enforce test identification and standard, predictable coding.
  • Clinical Edits flag tests that typically aren’t covered by health plans, such as experimental tests; tests not supported by patient age or gender; and tests not supported by specific diagnosis codes.
  • Coding Edits, such as invalid procedure codes, are based on the current procedure codes and the AMA’s coding guidelines.

The scope of claims addressed by the base package of edits includes:

  • Molecular Pathology
  • Genomic Sequencing Procedures and Other Molecular Multianalyte Assays
  • Multianalyte Assays with Algorithmic Analyses
  • Proprietary Laboratory Analyses (PLA) Codes

A Single Source for Genetic Test Edits and Policies

As a transformative payment integrity solution for payers, Source has developed partnerships with many different best-of-breed vendors, including Concert Genetics. As part of the Source ecosystem, Concert Genetics is able to leverage advanced APIs from Source to deliver pre-built integrations between the two systems.

This not only eliminates the IT burden for payers who want to use both solutions, but it also creates a more seamless user experience by giving users the ability to access the Concert Genetics rules and edits directly from within the Source interface.

To learn more about how Source + Concert Genetics and the entire Source ecosystem of third-party partners can help your organization increase accuracy and reduce waste when it comes to genetic testing claims, visit the Source third-party integrations page here.

About the Author

Carl works closely with healthcare payers and the intricacies of their data and IT ecosystems. His deep understanding of each payer’s unique needs helps to identify root-cause issues and solutions.

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