By InformedDNA

If they haven’t already, health plans will soon see a rapid rise in the number of members and providers asking whether genomic testing is covered and to what degree. Even though genomic testing may be a small part of a health plan’s benefits management program it can represent a meaningful portion of the risk. And a risk that will only increase if the health plan does not have a well-designed genomics benefit management (GBM) plan in place. Left unchecked, potential risks could grow due to the increasing number of people getting genetic tests and the precipitous upsurge in the number of new genetic tests entering the market—currently estimated at more than 167,000

There are key areas where the risks of insufficient GBM can have wide-reaching effects. 

Inconsistent medical reviews top the list. Without up-to-date genomic testing policy criteria and clear clinical guidance to support accurate application, it can be difficult to maintain a reliable genetic testing review process. This can lead to variations and irregularities, which have serious clinical, financial, and member experience implications. For example, inappropriate approvals increase the risk of unnecessary testing, which can drive up costs in terms of the tests themselves as well as the downstream care costs incurred as providers pursue unnecessary screening or treatments that stem from the inappropriate tests. Incorrect denials can lead to costly appeals and provider abrasion.

Lastly, an insufficient medical review program can cause an unnecessary burden on medical reviewers. Most reviewers don’t have a strong background or current familiarity with the clinical use of genetic testing. Without clear direction, reviewers may spend an inordinate amount of time researching the answers they need. Multiply that by an ever-increasing caseload, and it’s easy to see how the medical reviewer’s time can be swallowed up doing research. Moreover, if they don’t have access to the latest clinical information, they can obtain outdated, and potentially incorrect, advice, which can slow the approval process and further add to already full workloads, creating a cycle of job dissatisfaction.

Be aware of the regulatory risks as well. There are substantial regulatory requirements associated with coverage decisions and adverse determinations, interrater reliability, and burden of proof for evidence-driven policies. Without reliably sourced and up-to-date, evidence-based coverage criteria for genomics, a health plan can struggle with regulatory issues, which can have significant financial consequences. Additionally, the inability to ensure consistent application of medical policy amongst a review team can add to the potential regulatory risks for a health plan.

The solution! By working with genomics specialists like those at InformedDNA, you can take the guesswork out of genomic benefits management (GBM) and mitigate risks to member care, while improving member experience and the overall health plan business. 

InformedGENOMICSTM is a subscription-based program that includes evidence-based genomic coverage guidelines; a library of comprehensive literature reviews and references on hundreds of genetic conditions; coverage decision workflows for clinical reviewers; and detailed molecular CPT® code insights. 

To learn more about how we can strengthen your genomics benefit management program, keep it up to date and reduce inherent risk, please fill out the form below or email us at or call us at 844-846-3763.


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