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4 Ways to Maximize Revenue Regarding Genetic Testing

As genetic testing has continued to increase, reimbursements on genetic test claims remain a significant challenge for clinical laboratories and anatomic pathology groups.

According to Concert Genetics, the number of total genetic tests in 2012 was 10,000. By year-end 2020, that number had grown to 166,450 tests. Not only is the number of tests increasing, but the testing is becoming more complex as well.

Genetic tests have increased by more than 1,565% since 2012.

As a result, reimbursement difficulties and high denial rates are causing labs to experience substantial added administrative costs.

However, the recent webinar, “State of the Genetic Testing Marketplace – Getting Paid for All Your Lab’s Genetic Test Claims: What’s Changing, What’s Not, and What’s Working Best,” which is viewable on-demand now (see discount code at end of this post), explores how labs can avoid some administrative costs, increase cash flow, and lift the number of reimbursable genetic test claims.

Hosted by Dark Daily, the webinar featured panelist Heather Agostinelli, XIFIN AVP Strategic Revenue Operations, who discussed the significance of a robust revenue cycle management (RCM) system when trying to maximize revenue with genetic testing. In particular, when it comes to coding, billing, and collections regarding genetic tests, she said labs need to look at four areas that have become increasingly important to revenue:

  • Prior authorizations
  • Benefits investigation
  • Payor medical policy
  • Payor audit trends
Prior Authorizations

A prior authorization (PA), a process for pre-determining if a procedure or test is covered, is typically required by most payors for specific genetic and molecular laboratory testing. Common tests commonly requiring PAs include cystic fibrosis, ClariTest, Fragile X SMA, and STD testing (UHC).

“Prior authorizations started to explode a few years back and are now an enormous portion of what we deal with regularly,” Agostinelli said. “My PA department has grown from five people to more than 25 people just in the last year because PAs have become standard.”

Agostinelli listed some of the most critical PA challenges that labs face:

XIFIN helps cut your PA time by about 80%

  • Not meeting medical necessity
  • Not able to obtain the necessary documentation from the ordering physician
  • Ordering physician doesn’t initiate the PA
  • Missing the deadline with AIM
  • Ordering physician required to perform genetic counseling before the test is run and the PA is granted

“A big part of getting a PA is obtaining solid medical notes from that ordering and referring physician,” she said. “This is perhaps the biggest pain point. Because of the sheer volume of PAs being required and because each insurance company has its form, making it time-consuming, you should partner with a vendor who can get permission from the ordering physician to start and process the PA. XIFIN works with many vendors that allow us to enter that information and then translate it over to those particular payors.”

Benefit Investigation

Benefit investigation (BI) is another area seeing tremendous growth over the last 18 months. BI is when a lab quotes the patient’s estimated out-of-pocket costs based on the patient’s in-network or out-of-network benefits. The estimated out-of-pocket is determined by their deductible, co-insurance, and co-pay amounts. BI is not performed on Medicaid or straight Medicare policies.

“Why has BI exploded?” said Agostinelli. “Patients are likely shopping. These are very expensive tests, and they want to understand any out-of-pocket money they will owe to determine if they want to move forward with the test. The patient or the clinician usually requests the BI. If it’s the clinician, it’s a good idea to start that prior authorization process while you have them on the phone.”

Some of the common challenges when performing a BI include:

  • Patients with high deductibles opt for self-pay prices
  • Testing isn’t covered in genetics
  • Confusion surrounds insurance and deductibles
  • Patients wait to call after the sample is taken
  • Confusion over tests covered under regular deductibles versus diagnostic lab deductibles

“Patients often have high deductibles,” said Agostinelli. “In many instances, because of that, they will decide to do a self-pay rate. Before allowing a self-pay rate as an option, I advise that you talk to your legal counsel and make sure you’re buttoned up appropriately.”

Payor Medical Policy

Many commercial plans from the past used to follow Medicare, which would be used as a baseline for finding errors and edits. Today, Medicare doesn’t have nearly the policies in place that the commercial plans do.  So following the Medicare guidelines might not necessarily help you today because there are so many commercial payor plans for genetic testing and core testing in the lab industry.

Some of the current changes happening to payor medical policy include:

  • Commercial payors are increasingly creating their own medical policies
  • United Healthcare is the top payor with the most policies
  • Cigna, Humana, and Aetna have similar policies
  • Traditional Medicaids have strict policies and do not cover genetic testing

“Policies are constantly changing, so you want to ensure that your RCM system can upload the latest information so you can stop a claim and correct it before submission,” Agostinelli said.

Finally, she said that some of the pain points for labs regarding payor medical policy include not meeting medical necessity and understanding referral sources.

Payor Audit Trends

Agostinelli touched on payor audit trends that have made it difficult for labs.

Anthem has been hitting many national labs of all sizes with prepayment review audits. This audit typically requires that the lab provide the requisition, lab results, and ordering physician’s notes before submitting a claim. This audit type is being used with genetic testing, COVID, and women’s health. Prepayment review audits have been appearing for genetic testing and core lab testing under United Health Care.

One way to help in the administrative costs of audits is to have a purpose-built RCM, such as XIFIN RPM, to help automate the process.

For a summary of claims-side issues related to genetic testing reimbursement, view this handout.

Finally, Agostinelli said there had been necessity-type audits coming from all the payors. This includes anything centered around genetic testing. The most significant pain point here is obtaining the medical notes from the ordering physician. But within the XIFIN RPM system, there is a client portal that lets XIFIN retrieve that information with some ease.


The 90-minute webinar also covers:

  • Learn why payers must now deal with more than 5,000 new genetic tests launching every month and how that complicates claims processing
  • Understand how the variation in CPT coding by different genetic testing labs complicates claims processing by payers
  • Explore the challenges and opportunities to help payers apply their medical policies to genetic test claims
  • Understand why “benefit investigation” is already a huge factor as consumers seek the lab with the cheapest genetic test price before they agree to be tested
  • Master the art of working with prior-authorization programs and know why having documents prior to authorization still does not mean the payer will reimburse for that genetic test claim
  • Compare different tactics when payers audit genetic test claims and learn the right way to respond to documentation for medical necessity
  • Assess Medicare’s policy changes at the national level for genetic tests
  • Know the core elements of the Medicare MolDx program that governs genetic test claims across 28 states
  • Distinguish how the federal government’s Operation Double Helix cracked down on billions of dollars of fraudulent use of genetic tests
  • Use the Operation Double Helix court documents as the road map to identify the genetic tests and CPT codes that federal prosecutors use to guide their enforcement of the Anti-Kickback Statute, the Stark Law, and EKRA

Watch this webinar to hear more from Heather as well as fellow speakers Rob Metcalf and Bruce Quinn on the state of the genetic testing marketplace. 


Published by XIFIN
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