Tricare stopped reimbursing genetic tests

Tricare beneficiaries soon will have to pay out of pocket for certain diagnostic genetic tests that their civilian physicians order, but that the Defense Health Agency doesn’t view as appropriate or medically necessary. In January 2013, without notice to beneficiaries or to health care providers, Tricare stopped reimbursing clinical laboratories for more than 100 different genetic or “molecular pathology” tests. What drove the decision by Tricare last January to stop reimbursing for many genetic or laboratory-developed tests, aka Lets, was the AMA’s publication of new CPT codes for laboratory tests. The codes gave greater transparency to how Tricare was being billed, DHA said. It could “identify specific laboratory developed tests that 1) Have not been approved or cleared by the Food and Drug Administration and/or 2) Failed to meet Tricare criteria for coverage.” If Tricare doesn’t begin soon to pay for these tests, doctors won’t stop ordering them, but laboratories will have no choice but to charge patients for their cost. DHA has created two standards of care regarding molecular pathology tests. Patients who use civilian providers will have to pay for these tests, while patients at military clinics and hospitals won’t. Providers in the direct care system can continue to order such tests knowing the military will pay for them.