In the rapidly evolving healthcare landscape, the expansion of genetic testing is a huge step forward. The field of genetic testing has grown exponentially over the last decade, with the number of tests available increasing from 10,000 in 2012 to over 175,000 today – a staggering 1650% increase, with an estimated ten new tests being introduced every day. And as the connection between genetics and disease becomes better understood, genetic testing is being used in new disciplines. While this diagnostic revolution holds enormous potential to transform personalized medicine through early risk detection and personalized treatment plans, it also presents significant challenges – particularly when it comes to payment accuracy.
Current Challenges for Health Plans
As the use of genetic testing increases, health plans are grappling with challenges impacting appropriate spending, administrative costs and operational efficiencies. The most important topics include:
- Manual verification effort –– Although genetic testing only accounts for about 1% of all health insurance claims, it accounts for 15-20% of all medical services reviewed by health insurance companies, such as: B. prior authorizations and application reviews, resulting in a disproportionate burden on resources and increasing administrative costs.
- Disproportionate spending — Although they represent only 10% of all tests, genetic testing accounts for 30% of laboratory spending, reflecting their high cost and increasing use.
- Payment inaccuracy — The rapid pace of technological change, the increasing number of tests and the complexity of coding and billing processes present challenges for both providers and insurers and result in inaccurate claims and payment errors.
- Fraud and abuse — The potential for fraud and abuse in genetic testing claims is a growing concern. In recent years, several high-profile cases have highlighted the need for more effective fraud detection and prevention measures.
As health plans struggle to keep up with advances in genetic testing, there is an urgent need for solutions to streamline processes, improve accuracy, and reduce administrative burdens.
The power of strategic partnerships and specialized expertise
To address the complexity of genetic testing claims and align payment with appropriate rules and reimbursement methods, health insurance companies are increasingly working with specialized companies that have practical expertise in this area. These collaborations aim to bridge the gap between clinical knowledge and administrative processes and enable payers to better manage the intricacies of payment accuracy associated with genetic testing.
By leveraging the capabilities of specialized partners, health plans can access technologies such as AI-powered claims processing systems that can identify and correct coding errors, detect potential fraud, and ensure compliance with evidence-based policies and guidelines. These solutions not only improve payment accuracy but also reduce manual verification efforts for health insurance personnel.
Strategic partnerships can also help health plans stay ahead of the curve when developing policies and educating providers. Specialized companies often have dedicated clinical teams that continually monitor the latest advances and translate this knowledge into actionable insights. This includes developing guidelines for conducting genetic testing as well as educating best practices for ordering tests and submitting claims.
Recommended health insurance solutions
To better manage genetic testing claims and improve overall outcomes, health plans should consider the following recommendations:
- Implement a claims management solution for genetic testing that combines human expertise and AI-driven prepaid processing capabilities to accurately identify genetic testing services, apply transparent rules based on policy content, and reduce administrative burden and costs.
- Use the solution to improve consistency in coding and billing, reducing prior approval requirements and lowering administrative costs for everyone involved.
- Detect and prevent fraud, waste and abuse by identifying inappropriate coding practices and enabling rapid responses to fraudulent activity.
- Increase transparency and reduce friction between providers with consistent, reliable, predictable and transparent communication about coverage decisions for genetic testing services.
Collaboration, transparency and innovation
The key to success is fostering a collaborative ecosystem that prioritizes transparency, education and innovation. Health plans, partners and providers must work together to ensure the benefits of genetic testing are realized while maintaining payment integrity, which ultimately benefits patients by providing them with a clear understanding of not only their clinical situation but also their financial obligations .
This collaboration should focus on developing clear, evidence-based policies for insurance coverage and reimbursement: investing in solutions to automate claims processing and fraud detection, educating providers, and ensuring transparency between all stakeholders.
By leveraging strategic partnerships and innovative solutions, health insurers can address the complexity of genetic testing claims while unlocking the immense potential of precision medicine to improve patient outcomes and drive healthcare transformation.
Photo by Flickr user Petra B. Fritz
Brian Berkowitz is vice president of strategy and corporate development at Lyric, a health technology company dedicated to simplifying the business of care. He leverages his extensive, proven healthcare expertise and dynamic problem-solving skills to drive the company’s growth, helping to improve payment accuracy and integrity for eight of the top nine payers and many health plans serving more than 185 million individuals .