Payment Integrity Edits Identify $26.5M In Inappropriate Genetic Testing Payments

posted by AHIP

on January 21, 2021


With more than 75,000 genetic tests currently on the market2 and expected annual growth rates of 10% to 15%, spending on genetic testing is projected to increase from $13B in 2020 to $29B by 2026.1 While genetic testing delivers significant clinical value to patients, this explosive proliferation has created clinical and payment appropriateness issues.

Payers have addressed the clinical considerations by developing more sophisticated medical policies and implementing programs such as prior authorization and mandated genetic counseling. As a result, payers, providers, and patients are benefitting from the clinical improvements of these programs — with some believing that these initiatives eliminate the need for payment appropriateness.

This paper represents the views of the author, not America’s Health Insurance Plans (AHIP).  The publication, distribution or posting of this paper by AHIP does not constitute a guaranty of any product or service by AHIP.

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