Some of it is due to miscoding, due to the vast discrepancy between available genetic tests (175,000) and the Current Procedural Terminology (CPT) codes applied to the test (400). Unnecessary genetic testing (estimated at about 20-40% of dollars spent on tests) is also a factor. And part of it is due to a lack of genetic utilization management on the part of providers.

There’s a solution to all of those challenges – outsourcing your genetic testing utilization management to InformedDNA. We have the largest in-house staff of certified genetics experts in the country, and we are uniquely positioned to navigate the complexities of genetic testing payment integrity. We have worked with payers across the country in medical policy development and utilization management programs – imbuing us with an intimate understanding of the complexities of the payment process.

InformedDNA Payment Integrity includes an expert approach to identifying the specific testing being performed, an understanding of the clinical scenarios in which there is medical necessity for the testing and the relative standards for the determination, as well as the CPT coding landscape applicable to the testing. Unlike other large health plans finding themselves in the headlines for their use of flawed automated claims adjudication, with InformedDNA Payment Integrity, a payer can be confident that the solution implemented will accurately identify that the test performed is in alignment with the plan’s policies and national guidelines, and result in an extremely low rate of appeals.

InformedDNA has been able to achieve such a low appeal and overturn rate because of our thorough vetting of the evidence to make a determination, as well as the frequent review of changing sources of new tests and evidence over time.

Since each health plan is unique, savings opportunities may vary. However, in our experience within the prepay space, in one year for a single client, we have seen a reduction of genetic testing costs by $26.5 million dollars. And while savings may vary, we also know that if genetic testing is left unchecked within a plan, the spend will skyrocket given the volume of testing in the market. In fact, one health plan had a $48 million dollar increase in genetic testing spend over a one-year period.

Payment Integrity programs based on deep genetics and billing expertise can flag unnecessary tests and uncover improper billing patterns, thereby influencing lab behavior and identifying bad actors in the genetic testing space. This, in turn, not only helps health plans control costs but also helps healthcare providers and patients save time and risks. Implementing a Payment Integrity solution is a smart strategic move to help make healthcare more affordable to everyone.