Health Plans

Partnering with InformedDNA

NCQA

The only proven, full service genetic benefits management solution for health plans.

Promote consistent, evidence-based testing for your members while improving your bottom line.

Genetic testing spend continues to grow at about 15% annually. However, that doesn’t mean your plan has to accept high growth trends. The health plans we work with see a return of five times their investment or more by reducing or eliminating genetic and lab cost trends.

Learn how one plan decreased PMPM spending
on genetic testing by 48%:

Read the Harvard Pilgrim Case Study

See how our Payment Integrity Solution could help your plan reduce genetic test payments by 18-45%.

* HITRUST CSF Certification achieved for IDNAcentral™ and Client Data Analysis systems.

Co-Founder and Chief Medical Officer Rebecca Sutphen discusses health plan challenges with precision medicine.

In this three-minute video interview, Dr. Sutphen discusses the role of genetic testing in the growing area of precision medicine. She describes how InformedDNA works with our health plan clients to help ensure the most appropriate use of genetic testing, as part of bringing the promise of precision medicine to health plan members and providers.

Case Study

See how InformedDNA and Cigna’s partnership made an impact.

Cost Trend

Objectives

  • Eliminate upward genetic test cost trend

Results

Cigna’s genetic testing cost trend has remained relatively flat, compared to competitors with a cost trend up to 40%.

Since program inception, Cigna has experienced approximately 50% fewer Non-Specific Genetic Testing Code approvals, leveraging InformedDNA’s clinical expertise to help drive better medical necessity decisions.

Provider Support

Objectives

  • Promote evidence-based, medically appropriate testing
  • Reduce expense of denials, appeals and ultimate overturn
  • Improve provider relations

Results

When Cigna and InformedDNA collaborate with the ordering provider, about 50% of the time there is consensus that a more clinically appropriate test than the one initially ordered is available.

With valuable input and assistance from InformedDNA, Cigna consolidated coverage policies for genetic testing and reduced the number of policies from more than 30 to 8, which made the policies more clinically appropriate and easier to administer.

Customer Empowerment

Objectives

  • Empower customers to make informed medical decisions
  • Improve customer relations
  • Avoid unnecessary medical spend

Results

1 out of 5 individuals who received genetic counseling with proper informed consent decided not to pursue genetic testing.

Achieved 97% member satisfaction with genetic counseling services.

Solutions for Health Plans

Genetic Benefits Management™

Help ensure the most appropriate testing – based on current medical evidence.

InformedDNA provides clinical decision support on the appropriate use of genetic tests to three of the top five US health plans. Our program addresses every element of genetic testing management, from policy development through prior authorization and claims edits, counseling, lab network optimization and expert consulting.

Policy Development

Cover evidence-based, medically appropriate testing.

Our genetics specialists work with health plan medical management staff to develop evidence-based medical policy and coverage determinations for new tests and labs, based on a thorough and constantly up-to-date review of medical evidence. We also can incorporate your plan’s accepted medical policy with ours.

We employ a large, full-time team of board-certified genetic counselors and analysts with advanced degrees and experience in molecular biology, laboratory science, genomic research, public health, and bioethics.

Clinical Guidelines

Stay current as the field of precision medicine expands.

There are more than 140,000 genetic tests, with an estimated 10 more tests added every day. Our unique condition-oriented approach to guideline development, along with our substantial genetics expert staff, enable us to maintain out-of-the-box guidelines addressing all genetic tests. Thus you can manage high-volume and high-impact tests and the broad spectrum of available tests.

“InformedDNA’s genetics expertise and consultative services help us stay ahead of the curve in the rapidly changing field of genetic testing. Their telephonic genetic counselors extend our network and support our customers with convenient and comprehensive counseling that helps them make more informed decisions about potentially life-changing matters.”

– Jeffrey Hankoff, M.D., Medical Officer, Cigna

Prior Authorization

Bend the test trend curve.

In conjunction with our partner, AIM Specialty Health®, we provide a fully automated genetic test prior authorization service, including a provider portal that enables instant approvals for 80-90% of approvable requests. When manual review is necessary, our genetic analysts consider case-specific information and evidence-based criteria in recommending an outcome. We also guide providers to alternative tests and labs when indicated by medical evidence – automatically.

Learn how one plan decreased PMPM spending
on genetic testing by 48%:

Read the Harvard Pilgrim Case Study

Genetic Counseling

Empower members to make informed medical decisions.

We employ a large, full-time staff of board-certified genetic counselors nationwide, to provide guidance directly to your members and providers, as warranted by your medical policy.

Co-Founder and Chief Medical Officer Rebecca Sutphen is one of the few physicians board-certified in clinical genetics, molecular genetics, and cytogenetics.

Lab Contracting

Get the most value out of your lab network.

Our experience with millions of genetic test claims enables us to determine which labs offer the best value and reasonable billing practices. Our deep genetic test expertise enables us to understand which labs are most clinically appropriate to perform certain tests. We guide you on which labs are best to perform which tests for your members.

Consulting and Analysis

Drive additional savings and the most appropriate care.

Our genetic specialists can provide ad hoc or ongoing consulting support to assist with coverage policy, payment policy and lab network development. We also provide detailed analyses of genetic test utilization patterns and savings opportunities.

Payment Integrity

Eliminate genetic test claim overpayments.

About half of all unnecessary genetic test spend is from claims overbilling and overpayment. This is exacerbated by insufficient codes for test identification and the rise of gene panel billing. We provide claims edit algorithms that identify the specific tests performed, then apply evidence-based rules to block approval and payment of unnecessary claim line items or units.

Learn more

Precision Medicine Management™

Help ensure the most appropriate genetic therapies – based on current, complete evidence and our teams’ expertise.

Leveraging our genetic analyst team, who review more than 12,000 genetic test requests monthly, InformedDNA helps health plans manage extremely costly therapies associated with complex genetic testing. From policy development and case review to value-based contracting and patient education – our genetic analysts can help your plan avoid unnecessary therapy costs and ensure appropriate specialty therapies for your members.

Precision Drug Management™

Cover evidence-based, medically appropriate specialty pharmaceuticals.

Case Review: Especially for high cost orphan drugs, InformedDNA defines a genetic test selection and interpretation strategy that, combined with other biomarkers and phenotype information, enables our experts to make an evidence-based coverage recommendation. This approach helped one plan avoid $6.5M in inappropriate therapies in just ten months.


Genetic Counseling: Once the correct coverage decision is made, InformedDNA goes a step further by engaging its specialty-trained genetic counselors to meet with the patient/family to explain the decision in a respectful and accessible way. During this encounter we are able to leverage our genetics expertise to explain not only if and why a therapeutic was denied, but help families find clinical trials and other alternative support options.

Resources

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