Payment Integrity Edits Identify $26.5M in Inappropriate Genetic Testing Payments
Driven by the rapid and ongoing increase in the number of genetic tests available on the market, genetic testing spending is projected to increase from $13B in 2020 to $29B by 2026. The growth and complexity of these tests create clinical and payment appropriateness challenges. And, overpayments still occur even if a plan has an effective utilization management program in place.
In this case study, we describe the payment integrity program that InformedDNA implemented with a large national health plan with more than nine million covered lives. By improving test identification, reviewing claims against medical policy, and identifying payment variations, the program enabled $26.5M in payment reductions on edited genetic testing claims — a reduction equal to $0.25 PMPM.
With the nation’s largest employee staff of lab-independent genetics specialists, InformedDNA enables health plans to stay ahead of the curve by augmenting a plan’s in-house team with comprehensive clinical genetics expertise. We empower health plans to promote precision medicine, optimize spending, and avoid unnecessary and unpleasant experiences for members and providers.