Cost Management

GBM Reduces Genomics-Related Costs

There are more than 150,000 genetic tests on the market, with new ones arriving daily. This is only expected to increase with the genomic test market projected to surpass $37.7 billion by 2026, representing a compound annual growth rate 19.1%. InformedDNA’s holistic approach to genomic benefits management (GBM) provides evidence-based clinical guidance as a means to reduce suboptimal testing and decrease inappropriate spend on downstream treatments and procedures, which will otherwise continue to accelerate. Genomics expertise should be integrated into policies and workflows to streamline getting the right test ordered on the front end and ensuring appropriate billing and payment on the back end. Expert-powered policy development, prior authorization, and payment integrity are key.

Reduce Downstream Costs

One national payer had 75% of testing decisions impacted by the availability of a genetic counselor at the point of ordering. This includes provider withdrawal of unnecessary requests and redirection to alternate testing/coding—both of which reduce costly appeals downstream.

Expert Opinion Review

An effective approach to genomic testing spend demands access to genomics experts to augment in-house medical director expertise in the review process.

Expert-Built Claims Edits

Integrating claims edits and payment rules built by clinical genomics experts into the claims processing system can prevent overbilling and subsequent overpayment.

Genomics Program Analytics

Analytics for genomics must be highly adaptable and collaborative with stakeholder participation to identify key trends and continually enhance program performance to achieve maximal savings in the changing genomics landscape.

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This was probably the most pleasant insurance-related peer-to-peer conversation I have ever participated in. 

- Actual provider feedback

Provider Testimonial

It was nice to discuss this with a genetic counselor who understood where I was coming from regarding genetic testing.

- Actual provider feedback

Provider Testimonial

Increase Payment Integrity With Expert-Built Claims Edits and Payment Rules

InformedDNA’s GBM solution includes quarterly updates to claims edit and payment rules. Our approach uses expert-built algorithms to identify specific tests, run policy rules to catch claims that should not be paid, and applies edits to the identified tests. 

  • Prevent overbilling
  • Accurately enforce genetic testing policy               
  • Be prepared to address rapid developments in genomic medicine

Increase Opportunities With Network Management Analytics

  • Identify test ordering patterns and trends to guide policy development
  • Inform lab contracting rates and benchmarks to improve negotiations 
  • Share program outcomes to improve clinical decisions     
  • Standardize and optimize test pricing 
  • Set agreed-upon cap rules for the number of units charged
  • Support systematic lab benchmarking 

Eliminate Inappropriate Costs With Expert Clinical Guidance

An effective approach to genetic testing spend demands access to genomic evidence-based guideline criteria and genomics expertise that includes:

  • Evidence-based coverage criteria written by genomics experts and rigorously updated to include the latest evidence
  • Library of condition-specific literature reviews and key references to augment in-house genomics knowledge
  • Direct, one-on-one provider engagement and education
  • Coverage workflows and decision guidance for consistent and efficient medical director review
  • Network intelligence
  • Molecular test and code insight

Incorporating such elements into genetic testing decisions eliminates inefficient review costs and avoids unnecessary appeals. Allowing genomics experts to educate network providers and augment the clinical reach of your in-house team of medical directors with evidence-based genetic testing guidance can significantly reduce provider abrasion and boosts member satisfaction.

Our Latest Thinking on Genomics

Your Trusted Partner in Applying Genomic Science

InformedDNA is the nation’s first telehealth genomics services company. Our real-world clinical guidance, cost management and patient navigation solutions are built upon the most current genomics insights and are designed to optimize clinical decisions across the care delivery spectrum.

We have helped manage the health benefits of more than 100 million covered lives and have navigated hundreds of thousands of people to the right treatments or clinical trials.

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