At this year’s Executive War College (EWC) conference, it was my pleasure to present a session on “Best Practices in Genetic Test Coding, Billing, Collections, with Prior Authorization Insights.” It’s an important topic because the number of genetic tests being performed each year continues to grow and collecting the payment due for these services can be challenging.
Scientific and technical advancements mean that as an industry we have the ability to perform genetic testing for more conditions than ever before. In 2014, there were 66 genetic test procedure codes. Today, there are 365. In 2020, Medicare Part B spending for genetic tests was $1.2 billion, approximately 15% of total Medicare Part B spending. Just one year later, in 2021, Medicare Part B spending for genetic tests was $1.9 billion, 58.3% higher than the year before. This $1.9 billion represents 20.4% of the total Medicare Part B spending in 2021.
Medicare Part B Spend
Ensure Claim Requirements Are Met
There are four common challenges for molecular diagnostics laboratories that conduct genetic testing:
- Achieving and expanding payor coverage with coverage determination that defines reasonable and medically necessary services and tests
- Knowing how to code the tests correctly with medical nomenclature to report services and/or tests to a payor
- Ensuring payment/reimbursement for services/tests based on services/tests rendered and coverage determination
- Maintaining compliance and keeping abreast of billing compliance and having a voice in reform
Often, to achieve payor coverage for novel genetic tests, technical assessments are required to establish clinical validity and clinical utility. As important as achieving payor coverage is, it’s as important to understand how to code tests to facilitate reimbursement. At XiFin, we recommend that molecular diagnostics laboratories consult with coding experts to fully understand the coding requirements for each genetic test. To ensure reimbursement, it is also vital to know payor policies and to track denial trends by payor over time to identify changes.
Payor policies and behavior are constantly changing, and labs (and their billing partners) must stay abreast of changes to avoid lengthy delays that can be caused by denials and subsequent appeals. Understanding the documentation that is required with claims is also invaluable. Knowing these requirements up front and submitting complete claims with all required medical records and documentation of medical necessity goes a long way toward facilitating reimbursement.
Staying abreast of policy changes for Medicare and commercial payors enables laboratories to proactively employ front-end billing system edits to avoid denials. Regulatory research also helps with requisition design requirements. The XiFin team recommends molecular laboratories work in close collaboration with American Clinical Laboratory Association (ACLA), California Clinical Laboratory Association (CCLA), and other influential associations to leverage compliance and advocacy efforts.
The XiFin team also recommends that molecular laboratories conduct internal audits that reconcile laboratory information system (LIS) data with revenue cycle management (RCM) system data and that labs have a robust business intelligence (BI) solution to proactively identify outliers (i.e., accessions that exist in one system but not the other).
Maintain Your Billing System and Maximize Clean Claim Submissions
Molecular laboratories should be sure that these four payor services are being handled appropriately, whether it’s by the lab or an RCM vendor:
- Payor relations: An effective payor relations team monitors denials and coordinates with payors. This team reviews front-end payor rejections, coordinates with clients (i.e., ordering physicians), and identifies and updates edits based on changes in payor policies and behavior.
- Electronic data interchange (EDI) enrollment: This team handles monitoring and proactive enrollment for electronic submissions and helps ensure transaction automation.
- EDI analysts: Experts in healthcare EDI that investigate errors, participate in standards development and testing, as well as payor education and coordination.
- EDI operations: These specialized technicians configure files and ensure the reconciliation of claim-level submissions.
Efficiently Upload and Store Medical Records and Documentation
Although laboratories do not have direct control of patient medical records, it is important to understand that to maximize reimbursement for genetic testing, diagnosis codes alone are generally insufficient. Laboratory sales representatives must work with clients and ordering physicians to ensure medical records have all of the information required for payment. In addition, the RCM system must offer the capability to upload and store medical records and documentation. The required medical information typically required includes the following:
Who? Ordering/referring provider
What? What service(s)/test(s) is/are being ordered?
Where? Where is the specimen being sent?
When? What is the date of service (DOS)?
Why? What are the patient’s signs/symptoms or what prompted the test to be ordered?
How? How are the test results being used to manage the patient’s medical condition?
Six Steps to Ensuring Success
The following is a summary of the XiFin-recommended best practices for maximizing reimbursement for genetic tests.
- Align with payors on evidence requirements including clinical utility evidence, current billing policies, and preferred coding approach.
- Educate clinicians to ensure the completeness of medical necessity and medical record documentation.
- Leverage the support and advocacy of key opinion leaders (KOLs).
- Collaborate with clinicians on the prior authorization process.
- Select an RCM partner that helps you maximize process automation and front-end edits.
- Leverage a BI system that simplifies the tracking of key performance indicators (KPIs), helps identify payor policy and behavior changes early, and highlights changes in key business trends.
Additional Resources:
The molecular diagnostics industry is rapidly growing. Read our white paper, The Executive’s Guide to Molecular Diagnostic Market-Share Expansion, to learn practical approaches, process enhancements, and payor strategies essential to growing novel diagnostic market share.
Watch the Dark Daily webinar, An Essential Guide to Obtaining Z-Codes for Molecular and Genetic Tests, on demand featuring XiFin COO, Kyle Fetter. This webinar provides you with the information you need to ensure your laboratory is prepared and compliant when UnitedHealthcare’s claim process changes take effect.