Not long ago, the AMA highlighted the challenges surrounding prior authorization requirements put in place by health plans, citing survey data from 1,000 practicing physicians noting administrative burden and delays in care. While self-reported data, such as survey responses, should be taken with a grain of salt, it is clearly important to understand the challenges and opportunities for managing health care spending. Feedback from providers is valuable toward creating and improving programs that enhance the care of patients and create sustainable processes for providers. In the AMA piece that addressed prior authorization broadly, physicians expressed a concern regarding the potential for delays in treatment and subsequent adverse outcomes caused by delays. These concerns are likely more relevant to procedures such as imaging or surgery than to genetic testing.

Nevertheless, many health plans employ prior authorization as a chief utilization management tool for genetic testing because, while some medical procedures and lab tests are almost always utilized appropriately at a low cost and within clear guidelines, genetic testing has proven to be costly and widely ordered with great variability and, in many cases, with limited evidence of clinical utility. Additionally, many providers without genetics credentials report a lack of confidence in determining the best genetic test to order or how to interpret results. An appropriate prior authorization process can facilitate decision support for providers in ordering tests and connect them with genetics professionals who can assist with test interpretation.

The AMA, in partnership with other organizations representing health care providers and health plans, released a Consensus Statement on Improving the Prior Authorization Process. In the statement, the organizations made several recommendations for improvement across the whole spectrum of medical specialties. These recommendations align with the approach that InformedDNA takes for prior authorization in the genetic testing space.

Automation to improve prior authorization transparency and process efficiency

Automation and real-time authorizations are absolutely key to integration of the prior authorization process into provider workflows. Our automated prior authorization algorithms are written by genetics experts with deep subject matter expertise and years of clinical experience. With our partners at AIM Specialty Health®, we are able to give providers a real-time “yes” answer in 65% of cases. When complex requests require additional review, InformedDNA’s staff of genetic analysts (board-certified genetic counselors with specialized training in evidence review) is highly effective in reaching providers to provide decision support. This allows for real-time modifications to test requests when necessary.

Review/adjustment of prior authorization lists to remove services/drugs that represent low-value prior authorizations

While each of our health plan clients has unique priorities and goals, InformedDNA recommends prior authorization for tests that are highly misused or expensive, or where it provides opportunity for provider education and decision support. We have advised health plans to remove commonly ordered tests with high compliance from their prior authorization program following user data analysis. This approach focuses on high-value prior authorization cases.

Transparency of prior authorization requirements and their clinical basis to patients and physicians

InformedDNA partners with AIM Specialty Health® in creating publicly available Clinical Appropriateness Guidelines for Genetic Testing. These guidelines and clear medical necessity criteria are designed with the clinician in mind. They are designed to make the prior authorization as streamlined as possible. The guidelines are organized by condition, address 100% of genetic tests on the market, and their organization minimizes confusion for providers trying to apply the correct medical policies in clinical practice.

In an effort to support communication channels between health plans, health care providers and patients, our genetic analysts initiate real-time discussions with providers before an adjudication is rendered. Collaborating with providers to navigate payer networks and medical necessity criteria on a case level creates greater  transparency. Based on our communication with providers on behalf of payers, InformedDNA has a 97% provider satisfaction rate.

Protections of patient continuity of care

InformedDNA approaches prior authorization for genetic testing in a timely manner, adhering to strict turnaround times for adjudication, which avoids disruptions in care. Because treatment may sometimes depend on genetic status of a patient, it is vital that the correct course of testing be pursued. Prior authorization for genetic testing allows the opportunity to ensure the most appropriate testing is utilized and can facilitate changes to the plan for testing when needed, enhancing patient care.

Pre-test genetic counseling by a board-certified genetics expert is an essential component of quality care in genomic medicine and is recommended by multiple professional societies. We empower providers to maintain stewardship of their patients by allowing for a referral for genetic counseling services in a timely manner and augmenting their practice staff with access to genetic counselors without the need to refer the patient to an outside facility for services. Pre-test genetic counseling leads to empowered decision making and support for the patient and provider.

Selective application of prior authorization to only “outliers” (vs. bluntly across all physicians)

InformedDNA works with many payer clients advocating for precision use of prior authorization, though data show that genetic testing management may benefit essentially all providers. Genetic testing is an explosive and rapidly changing field, one in which many non-genetics providers lack sufficient training. The speed at which genetics is reaching into all areas of medicine often outpaces the training available. Surveys of non-genetics providers show that a significant number do not feel knowledgeable about clinically available genetic testing and even more rate their understanding of genetics as  poor.

Data from our own work with payers shows that when an InformedDNA genetic analyst had a clinical conversation with the ordering provider, a more appropriate test was agreed upon 27% of the time. Our approach to genetic testing prior authorization aligns with AMA recommendations and brings value not only to payers as a form of management, but to providers through decision support and guidance.

InformedDNA leverages the expertise of the largest, most experienced, full-time staff of lab-independent, board-certified genetics specialists in the U.S. to help ensure that health planshealth systems, hospitalspharmaceutical companies, clinicians and patients all have access to the highest quality genetics services.

Additional resources:

  • Blog: Reducing Genetic Test Complexity, Confusion and High Costs Through a Condition-Specific Approach to Policy Coverage
  • Informed Insights, original research & analysis: An Inventive Approach to Genetic Test Policy Development for Health Plans
  • Washington Examiner opinion piece: Prior Authorization is Smart Medicine

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