Payers Turning to Automated Pre-Approval Systems for Genetic Tests

Payers are turning to automated systems for pre-approval of genetic tests as a way to contain costs and ensure proper utilization in the face of a dizzying number of news tests. UnitedHealthcare released a network bulletin in August 2017 announcing it will be implementing a national online prior authorization program for genetic and molecular testing performed in an outpatient setting effective Oct. 1 for its fully insured commercial members. Anthem Blue Cross implemented AIM Specialty Health's Genetic Testing Solution July 1 for fully-insured and self-insured members, and will add national account members in 2018.

The payers say that these automated processes can streamline prior authorization for providers, while laboratories are hopeful that automating the approval process can bring more transparency and predictability to coverage and reimbursement decisions, and potentially, can reduce the number of appeals for notoriously frustrating struggles for payment for molecular tests.

While new for the diagnostics industry, the use of automated pre-approval systems or benefits management is not new for payers. The systems for genetic test management are analogous to efforts to rein in overuse of expensive imaging or prescription drugs. Payers say this solution is needed for molecular testing because managing costs and utilization is nearly impossible in the face of the rapid pace of development and the sheer number of new, complex commercially available tests.

Anthem Blue Cross
Anthem's online platform is being administered by national specialty benefits manager AIM Specialty Health (AIM, a wholly- owned subsidiary of Anthem, Inc.) and was developed in partnership with InformedDNA, a genetic testing clinical decision support and genetic counseling services company.

"While the use of genetic testing has become more common, its complexity has often left both consumers and physicians without the expert guidance they need to decide which tests are most appropriate, what their test results mean—or whether they should have genetic testing at all," said Brandon Cady, president and CEO of AIM, in a statement. "Through our newest solution for genetic testing management, we are offering the market a unique approach and highly automated system that incorporates a requirement for genetic counseling into the clinical review process."

AIM says its Genetic Testing Solution improves efficiency for laboratories, doctors' offices, and insurers by shifting practice away from "a manual, labor-intensive and post-service process" to a real-time automated system. The company says the average time for submitting and processing an insurance claim can be cut from days to minutes because the prior authorization review provides specific CPT code information to the insurer to facilitate the claim processing.

AIM customizes the tool for each of its clients according to its unique genetic testing medical policies, which in the case of Anthem is 47. Within the Anthem program, the company says, that after the provider inputs information about the gene they want to test and the test they want to order, the platform generates the CPT code. This is a core benefit of the system for the insurer, as CPT codes are not unique to a specific test. Experts estimate that there are fewer than 200 billing codes for approximately 70,000 commercially available genetic tests. One CTP code can be applied to multiple tests that may differ in terms of number of genes assessed and test performance. While payers are seeking clarity on what they are paying for, laboratories are concerned that the automated systems will negatively impact coverage decisions.

UnitedHealthcare
UnitedHealthcare released a network bulletin in August announcing it will be implementing a national online prior authorization program for outpatient genetic and molecular testing (including Tier 1 and 2 molecular pathology procedures, genomic sequencing procedures, multivariate assays with algorithmic analyses) effective Oct. 1 for fully insured Commercial members.

United Healthcare will only authorize payment for those CPT codes that have been registered with the Genetic and Molecular Testing Prior Authorization Program for each specified genetic test. According to Xifin consulting firm, it is the laboratory's responsibility to determine if an authorization has been received as services rendered without an authorization will be denied and the member cannot be balance billed.

Takeaway: Payers hope that automated prior authorization will improve their efforts to manage utilization of genetic tests. However, laboratories remain wary that such systems will expedite their reimbursement.