Prior Authorization Policy Changes Help Grow Genetic Counselor Roles in Lab Reimbursement

NEW YORK (360Dx) –As genetic testing grows, moves by insurers to increase controls on prior authorizations for lab testing is growing the role of genetic counselors in lab reimbursements, genetic counselors and insurers said.

"We want to make sure UnitedHealthcare members have the best information possible about their healthcare options so they can make informed decisions with their care providers," said Lynne High, UnitedHealthcare director of communications. "A genetic counseling visit with an independent counselor removes potential conflicts of interest that could arise if a genetic testing lab was providing the counseling on services they perform."

UnitedHealthcare, through its relationship with Beacon Laboratory Benefit Solutions, stopped allowing labs to complete the prior authorization process for a member or ordering care provider on Nov. 1 2017, High confirmed. UnitedHealthcare's move followed that of Anthem BlueCross BlueShield, which made a similar move on July 1 in partnership with its own lab benefit management subsidiary, AIM Specialty Health.

The impact of those changes was felt quickly by labs and companies that provide genetic tests. During NeoGenomics' third quarter earnings conference call, Chairman and CEO Douglas VanOort cited the changes as a contributing factor to higher-than-expected debt in that quarter.

"In many instances, the preauthorization must be secured by the physician ordering the test rather than by the lab. If the required reauthorization is not included, payors will often deny the entire claim," he said, though three months later in the fourth quarter conference call he noted the company had set up ordering and billing processes to address the new requirements.

Those adjustments also had a big impact on genetic counselors, according to Erica Ramos, president of the National Society of Genetic Counselors.

"Obviously when big changes like that take place there are always some hiccups and one of the things that we did at NSGC was really to work with the insurance companies on behalf of our members and the patients they serve to provide feedback to payors on those issues," Ramos said.

The NSGC has worked with the insurers to rectify problems that genetic counselors have had with the new prior authorization systems, including difficulty in requesting a peer-to-peer review through the system and some problems that independent genetic counselors had with setting up accounts on the system, Ramos said.

Genetic counselors say that are seeing increasing involvement in test ordering as a result of new insurer policies.

"In some instances insurance companies are requiring that patients see a genetic counselor for certain genetic tests in advance of that testing being performed," said Kiley Johnson, senior director of genetic counselors at GeneMatters, a firm that provides genetic counseling services remotely through phone consultations and a HIPAA-compliant telehealth platform. "The reason for that is they want to be sure that the patient is the most appropriate person to be tested and that the right test is being ordered. There are so many more genetic tests now that it is becoming increasingly difficult for providers who aren't in genetics to know what tests they are ordering and whether they will really get the answers they need for their patients."

It is often the labs that take a proactive role in including genetic counselors in the test ordering and prior authorization process, Johnson added.

"Oftentimes physicians will order genetic tests for patients that they feel are helpful and relevant based on family or personal history. Those tests get to the lab, and the lab recognizes when it gets the insurance information that this happens to be an insurance provider that requires genetic counseling in advance and it wasn't done," Johnson said. "That can sometimes end up creating a bit of a cascade that sends the lab back to the provider's office to say this is a requirement for us to even be able to proceed with the test."

Prior authorizations are used by insurers to verify that the services they are paying for are appropriate for the patients who receive them, but tighter policies around them have caused many in the industry to express concern that policies are becoming too restrictive.

"Prior authorization is intended to support clinically- appropriate care. At the same time, when prior authorization is used to deny or discourage use of clinical lab tests, it poses a serious risk to patient care," said Julie Khani, president of the American Clinical Laboratory Association.

Some however, suggest that the opposition to prior authorization may be partly because it hasn't been as widely used in pathology as other areas.

"My personal point of view is that prior authorization is pretty standard for other procedures, for radiology and pharmacy, so doctors are pretty used to it. Pathology is probably just getting started," said Robert Boorstein, medical director of Clinical Genomics in Bridgewater, New Jersey and Lenco Diagnostic Laboratory in Brook. "I understand people would rather not get it, but I also think that for the insurance companies that are writing the checks, it's a way they are going to enforce that the people who get the tests are the people who need them."

Some of the frustration for labs may stem from the fact that currently many labs don't realize that they need prior authorizations until they have already incurred costs associated with receiving the specimen, according to Walt Williams, director of revenue cycle optimization and strategy for Quadax. Often, patients schedule an appointment, see a doctor who may collect specimen at that visit, and then the specimen can be sent to the lab within 48 hours.

"You've certainly absorbed now the full cost of acquiring that specimen, transporting that specimen, all the consumables, your kit, all the accessioning and then there's the additional cost of performing the test in your lab," he said during a recent webinar.

Lab procedures need to evolve to a state where prior authorization discovery happens earlier in the process, Williams said.

Genetic counseling company InformedDNA has a partnership with AIM Specialty Health, the laboratory benefit management arm of Anthem, which over the summer became the first major insurer to change course and no longer allow labs to order prior authorizations directly. However, InformedDNA's relationship with AIM is not that of a typical genetic counseling role.

InformedDNA began branching out from providing traditional genetic counseling services about five years ago to also provide lab benefit management services to insurers directly. The company also provides consulting services to health systems to help them develop genetic testing that's evidence-based, according to Amber Trivedi, InformedDNA chief innovation officer. These services were a natural outgrowth of the company's genetic counseling expertise, according to Trivedi.

"As we built genetic counseling relationships with large health plans, like Aetna, Cigna, and United Healthcare, they reached out to us for advice on how to keep their medical policy up to date as genetic test offerings, volume, and costs have continued to grow rapidly," she said.

Through the AIM Speciality Health partnership, InformedDNA used its genetics expertise to codify health plan policies into AIM's ProviderPortal, to enable ordering providers to make real-time determinations on approximately 85 percent of genetic test prior authorization requests, using evidence-based clinical review data, according to Trivedi. Anthem was the first client to use InformedDNA's services in this way, she said.

InformedDNA provides prior authorization services to insurers through a suite of clinical questionnaires that can be used online to document medical necessity and provide a real-time response to prior authorization requests. The InformedDNA system can also redirect lab test orders to in-network labs, according to Trivedi. The company also provides insurers with automated claims management for lab tests that don't fit the prior authorization system. Automated claims management helps match codes to genetic tests, Trivedi says.

"Right now there are 200 codes for more than 65,000 tests, so a good chunk of unnecessary [spending] comes from health plans paying more when they can't tell exactly what they are getting billed for," Trivedi said.

Those challenges may continue to grow. The research firm Research and Markets predicts a 10 percent compounded annual growth rate will take the global industry to 5.8 billion in 2022 from 4.6 billion in 2017.

InformedDNA's services also include "lab benchmarking services" to help insurers determine fair market value for tests based on data on prices for tests across health plans and the Medicare fee schedule, Trivedi said. The company also works with insurers on coverage policy development, she added. Trivedi said InformedDNA insurers who have implemented their lab benefit management services have reduced their spending on genetic testing by 25 to 40 percent.

Meanwhile, on an industry level, the NSGC does not work directly with insurers on lab test policy coverage development like InformedDNA, but it does advocate for certain policy positions on behalf of the industry, said Ramos.

"We wouldn't provide direct advice to insurers, but the way we do that indirectly is by supporting the development of practice resources, practice guidelines and policy statements," Ramos said. "Our practice guidelines are all evidence-based and they all meet the standards for national guidelines and are really done in a very rigorous way. We consider it core enough to our organization that it's actually one of our key committees that we run as an organization."

Separately, the association provides feedback to Evidence Street, a platform from the BlueCross BlueShield Association that collect evidence-based reviews for different lab tests and medical procedures, Ramos said.

In 13 years of practice as a genetic counselor, Johnson said the explosion of genetic testing has contributed significantly to the complexity of determining reimbursements for genetic testing.

"If you look at the NSGC communications back and forth you would see that definitely things have become more complicated," Johnson said. "We all want to work very collaboratively to bring appropriate stakeholders together from the perspective of insurers, patient advocates, genetic counselors, healthcare providers, and laboratories to say how do we do this more effectively for patients at the end of the day. "