With nearly 160,000 genetic tests available in the US alone, and an anticipated global market expansion to 436,000 tests by 2026, the need for cost containment strategies has never been more urgent for health plans.

However, the complexity and unregulated nature of this space creates a breeding ground of egregious coding and billing practices. With only 400 CPT codes for 160,000 tests (and growing), labs resort to unbundling, code stacking, and miscoding, which not only inflate costs, but also disguise a test as medically necessary, when it is not.

While prior authorization (PA) programs aim to help, the volume of PAs for genetic testing alone is difficult to keep pace with, creating more administrative burdens and dangerous care delays for patients. Moreover, PA alone cannot address wide genetic test variability between labs and the numerous CPT and International Classification of Diseases, making accurate test identification nearly impossible.