More than 70,000 genetic tests are on the market, with 8 to 10 new tests released each day. But as health insurance providers struggle to manage genetic tests appropriately, one area of hidden costs often is overlooked: overbilling for genetic tests.
Research shows 30 percent of genetic testing claims are coded inaccurately—and this has a significant impact on the expense health insurance providers incur for genetic tests. Other factors that contribute to higher-than-necessary costs for genetic testing include lack of medical necessity, volume billing (such as unnecessary multiple unit billing), and widely variant allowed amounts for the same test. Substantial savings opportunities exist even when the plan maintains an effective utilization management program for genetic tests.
This webinar will explore four practical strategies for reducing unnecessary genetic claims payments, which typically occur when:
• Payers’ claims systems can’t identify the actual test performed;
• Codes, or unit counts of codes, are inappropriate to bill for the specific test;
• Non-covered tests are billed and paid;
• Allowed amounts vary 10-20X for the same test.
For example, a close look at pharmacogenetics claims for one health insurance provider revealed expenditures of $12.9 million for tests that were not medically necessary based on plan policy. Additionally, high variability in pricing for pharmacogenetic tests, with many tests billed for $2,000 or more, as well as abuse of stacked and unlisted codes contributed to a 40 percent growth in genetic test spending in unmanaged areas within a year.
This session will enable attendees to evaluate and address the genetic test claims challenges their teams face and identify practical strategies for reducing unnecessary genetic testing spend.
Amber Trivedi, MS, CGC,
Chief Innovation Officer
Amber Trivedi, MS, CGC, leads InformedDNA’s innovation teams, bringing to market expert genetics services that keep pace with emerging technology and practices. Amber came to InformedDNA from the Northwestern Ovarian Cancer Early Detection and Prevention Program and the Division of Reproductive Genetics at Northwestern University. She was formerly a breast cancer researcher at UCLA and Northwestern University. Amber earned her bachelor’s degree in behavioral biology from Johns Hopkins University and her master’s degree in genetic counseling from Northwestern University.
Vice President, Client Development
John Gaines has more than 30 years of diverse experience across health plans, health systems, physician organizations and healthcare IT vendors. John leads a number of growth initiatives for InformedDNA, including management of key relationships. Previously, John was at McKesson Corporation, where he helped lead the growth of the company’s genetic test-related products. John has also held leadership positions with PricewaterhouseCoopers, Montefiore Medical Center and Siebel Systems. He holds a BA in Economics from Cornell University.