McKesson Corp. and MuirLab working to implement lab-friendly strategies to meet payer needs
Unfolding events make it likely that genetic testing will become a good news/bad news story for local clinical laboratories and pathology groups. The good news is that genetic tests and molecular assays will bring more diagnostic precision to patients and their physicians—and that points to an auspicious future for pathology and laboratory medicine.
The bad news is that payer requirements in the United States for pre-authorization of genetic tests may lock-out most local laboratories as providers for these specialized and important clinical laboratory tests. That’s the irony of this developing trend!
Just as local clinical laboratories and community pathology groups are positioned to deliver the next-generation of useful genetic tests and assume a closer role as diagnostic consultant to referring physicians, health insurers may be preparing to slam the door shut on their participation.
Pre-authorization of genetic tests is the payers’ response to the proliferation of expensive genetic tests, not to mention the fact that these genetic tests often trigger a therapy that requires use of expensive prescription drugs costing as much as $10,000 to $100,000 per patient. This situation is why payers want to ensure proper utilization of genetic and molecular testing.
Pre-authorization is one way for the payer to verify that the patient is an appropriate candidate for the genetic test that the physician wants to order. Pre-authorization also gives the payer the opportunity to arrange for genetic counseling so as to guide the patient to the right decision about therapy.
Payers and a brand-new class of healthcare company—the genetic benefit manager (GBM)—are planning to institute pre-authorization policies that, based on existing laboratory contracting policies, may soon raise significant barriers for participation that will effectively deny local labs and pathology groups access to patients who need genetic tests and molecular assays.
The reasoning behind such a prediction is simple. In order to pre-authorize genetic tests and expensive molecular laboratory tests, managed care companies and these new genetic benefit managers will want to create laboratory networks and laboratory provider panels which include only those clinical labs and pathology groups which meet the criteria established by the health plan. The experience of the past 20 years tells us that, when payers create these types of laboratory networks and lab provider panels, they tend to readily include national laboratory companies and only allow a handful of local or regional laboratories as providers.
Thus, the emerging trend of genetic test pre-authorization will be déjà vu for pathologists and clinical laboratory managers in local labs, pathology groups, and hospital laboratory outreach programs. The Dark Report and Dark Daily have been first in the laboratory testing industry to call attention to these important developments. Today’s e-briefing continues that valuable service to clients, subscribers, and readers.
Every medical laboratory in the United States needs to prepare a strategy for how it will respond to pre-authorization programs developed by the major health insurance plans serving their regions. If healthcare is about to enter the era of genetic medicine, then all clinical laboratories and pathology groups must be ready to respond so as to retain access to the patients and be paid adequate reimbursement for the molecular testing they perform.
To aid pathologists and clinical laboratory managers in this effort, The Dark Report has arranged for a special audio conference on Tuesday, July 13, 2010 at 1 P.M. EDT, titled “How Your Local Laboratory Can Win a Place at the Table When Payers Require Pre-authorization of Genetic Tests and Other Expensive Clinical Laboratory Assays”
The content of this special audio conference is designed to give clinical laboratory managers, pathologists, and the lab’s managed care contracting managers a detailed overview of this important trend. Payers will start with pre-authorization of the most complex and expensive molecular assays. But the long-term goal of health insurers is to establish a two-way relationship with laboratories that ensures “the right test, at the right cost and the right time.”
To provide this detailed overview of payers’ plans for laboratory test pre-authorization, Matthew Zubiller, Vice President and General Manager of Advanced Diagnostics Management at McKesson Corporation, will discuss why health insurers are moving in this direction. He will also share how his new business unit is developing lab-friendly services that will help local clinical labs, hospital outreach programs, and pathology groups participate in these payer lab test pre-authorization programs.
The second speaker during the July 13 audio conference will be Michael Tarwater, who is Executive Director at MuirLab, located in Walnut Creek, California. MuirLab is one of the most successful hospital laboratory outreach programs on the entire West Coast. It has been in the thick of the earliest efforts by California’s aggressive managed care companies to enact genetic test pre-authorization.
Tarwater will share how MuirLab is responding to payer requirements for pre-authorization for certain types of clinical laboratory tests. He will also provide details of how insurers in his state are developing laboratory provider networks for these laboratory tests. His lab’s experience is invaluable for pathologists and laboratory managers seeking to understand this disruptive new trend.
To participate in “How Your Local Laboratory Can Win a Place at the Table When Payers Require Pre-authorization of Genetic Tests and Other Expensive Clinical Laboratory Assays,” CLICK HERE to register and get the full details for this important session.
Pre-authorization of expensive molecular tests has the potential to be highly disruptive, particularly to the nation’s smaller, local laboratories. Dark Daily is bringing together, Zubiller and Tarwater to help proactive pathologists and laboratory administrators understand this nascent trend and get the information they need to craft a winning strategy for their laboratory organization. Informal question and answer sessions during the audio conference will allow participants to ask questions of particular interest to their laboratory and marketplace.
Since pre-authorization and related payer requirements on genetic and molecular testing have yet to become widespread, there is still time for all laboratories to do their homework on these developments and prepare an effective response. Opportunities like this audio conference “How Your Local Laboratory Can Win a Place at the Table When Payers Require Pre-authorization of Genetic Tests and Other Expensive Clinical Laboratory Assays,” are one way to stay on top of these forward-moving events.