Physician use of genetic tests continues to grow at robust rates, even during the pandemic, but uncertainty about managed care reimbursement hangs over the market

It may surprise many pathologists and clinical laboratory managers to learn that the market for genetic testing is robust and growing swiftly, even in the midst of the COVID-19 pandemic. At the same time, the explosion in both the number of unique genetic tests available to physicians, and the willingness of doctors to order genetic tests for their patients, are creating major challenges for both government and private payers. 

Moreover, how payers are attempting to gain control over this boom in genetic testing is creating serious problems for genetic testing companies seeking reimbursement for their test claims. This is because health insurers are taking aggressive steps to control their spending on genetic tests. Some of those steps include:

  • Prior-authorization requirements for an ever-larger number of genetic tests.
  • Reducing the prices paid for high-cost genetic tests.
  • Tough audits that use sampling and extrapolation and produce sizeable recoupment demands.

Unexpected Developments in Genetic Test Marketplace

These are reasons why clinical laboratories need to fully understand the state of the genetic testing market. Physicians are receptive to ordering genetic tests that will improve the care they provide their patients. But health insurers want better control over the unplanned and substantial increases in the total amount of money they pay out for the surging number of genetic test claims.

Collectively, these developments confront genetic testing companies with a mix of good news and bad news. The good news is that more physicians are using genetic tests in their daily medical practice. The bad news is that many payers are erecting ever-more restrictive hurdles that labs must overcome when submitting genetic test claims and seeking adequate payment.

To help executives and molecular pathologists from genetic testing laboratories understand the forces now shaping genetic testing in the United States, Dark Daily is presenting a special webinar, titled, “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.” This webinar—which includes a panel discussion and live Q/A session— will take place on Thursday, March 25, 2021, at 1:00 PM EDT.

Strategic Insights into What’s Changing with Genetic Testing

This webinar will be one of the most important strategic assessments of genetic testing presented to the clinical laboratory and diagnostics industries since the COVID-19 pandemic began last March. Your presenters are recognized thought-leaders in the genetic testing and laboratory medicine industries. Speaking in order are:

  • Bruce Quinn, MD, PhD, Principal, Bruce Quinn Associates LLC, Los Angeles: An expert in how Medicare and private payers establish coverage guidelines and prices for new genetic tests, Dr. Quinn will explain the key differences in how private payers are managing genetic test utilization and payment, compare to the federal Medicare program.
  • Heather Agostinelli, Asst. Vice President, Strategic Revenue Operations, XIFIN Inc., San Diego: Heather will provide a detailed perspective on the daily actions by payers as they process claims and issue payment for genetic tests. She will also present recommendations for how labs can optimize the number of clean genetic test claims, thus helping shorten payment times in ways that improve cash flow.
  • Rob Metcalf, CEO, Concert Genetics, Nashville, Tenn.: He will discuss the scope and scale of the explosion in the number of genetic test claims by sharing data, charts, and analyses usually only available to clients.

Your Chair and Moderator will be Robert L. Michel, Editor-in-Chief of The Dark Report.

Bruce Quinn, MD, PhD,  Heather Agostinelli, and Rob Metcalf headshots
On Thursday, March 25, at 1:00 PM EDT, Bruce Quinn, MD, PhD, (left), Heather Agostinelli (center), and Rob Metcalf (right) will present “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.” Molecular pathologists, financial analysts, and managed care and clinical laboratory executives will gain a critical understanding of how COVID-19 is shaping the future of genetic testing and learn how to navigate federal regulations and payer claims processing. (Photo copyright, Dark Daily.)

The purpose of the upcoming webinar includes helping attendees with the following and more:

  • Learn why payers must now deal with more than 1,000 new genetic testing products 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.
  • Learn 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 necessarily mean the payer will reimburse for a genetic test claim.
  • Understand Medicare’s policy changes at the national level for genetic tests.
  • Know the core elements of the Medicare MolDx program that gov-erns genetic test claims across 28 states.
  • Be prepared to 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 federal Anti-Kickback Statute, Stark Law, and the Eliminating Kickbacks in Recovery Act (EKRA).

Valuable Information for Financial Analysis, Managed Care Executives

In addition to bringing clinical pathologists and directors/managers of clinical laboratories up to date on the genetic testing marketplace, this webinar will provide valuable insights into financial analysts’ tracking of genetic testing companies, managed care executives’ handling of genetic testing claims, genetic counselors, and others involved in managing clinical service lines that utilize genetic tests in patient care.

Click here for full details or to register for the March 25 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.” Or copy and paste this URL into your browser:

—Michael McBride

Related Information:

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

Stark Law and Anti-kickback Statute to Encourage Value-Based Care and Reduce Technical Trip Wires

Federal Anti-Kickback Statute Final Rule

Physician Self-Referral Stark Law Final Rule

S.3254 – Eliminating Kickbacks in Recovery Act of 2018

Federal Law Enforcement Action Involving Fraudulent Genetic Testing Results in Charges Against 35 Individuals Responsible for Over $2.1 Billion in Losses in One of the Largest Health Care Fraud Schemes Ever Charged