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Payment Integrity Solution 

Improve payment accuracy for genetic testing and complex -omic testing with automated speed and industry-leading expertise

Payment Integrity Designed With Health Plans in Mind

The explosion of genetic tests is creating cost containment challenges for health plans across the board. Fraud, waste, and abuse issues in coding and billing practices are rampant and complicated. Without specialty expertise, health plans can’t identify these issues or decipher what they are paying for.

InformedDNA’s comprehensive Prepay and Post-Pay Payment Integrity Solution is custom designed to be implemented where each health plan needs it most. Whether it’s a prepay environment to avoid inappropriate payment, or post-pay to identify overpaid claims for savings to recover, we meet you where you are to ensure that health care dollars are spent in the most clinically appropriate ways. 

Measurable Payment Integrity Challenges

Projected CAGR for
genetic tests
10% - 15% 
CPT® codes
representing over
175,000 genetic tests
Only 0
genetic tests
associated with
CPT® code 81479
0 +
of dollars spent on
genetic test claims
are not warranted
Up to 0 %

Avoid Unnecessary Costs With Prepay Prevention and Proficiency

Custom implementation to fit each client’s needs

Our Payment Integrity Solution implements claims rules in the format you prefer with minimal interruption or changes to internal operations or workflows. Whether direct to health plan or adjudication partner, our experience shows and makes optimal use of budget, time, and resources required. There is no one-size-fits all approach, and whatever your plan’s philosophy, we make it work to fit your needs.

Ongoing quality controls for optimal savings

Ensure you’re up-to-date and stay that way through our active maintenance of your solution. We continuously vet medical evidence and monitor regulations — employing smart technology and smart genetic analysts — to deliver the most current claims edits to your prepay claims editing process for optimal performance. 

Prevent inappropriate payment of claims with up-to-date claim edits

Accurately identify genetic tests and edit claims based on the most current clinical and coding best practices. Our Payment Integrity Solution roots out variable coding and patterns of abuse in your claims environment, applying edits with automated efficiency, consistent with your medical policy to prevent incorrect payments before they happen.

Minimize appeals and overdenials with extensive support

Receive all supporting documentation for all claim edits, including the edit rationale, frequently asked questions, and the necessary information that could be submitted and change the determination. Lock in a defensible case for each claim and appeals defense as well as subject matter expert testimony in appeals trials.

In 1 year, for one health plan client, our solution 
impacted 17,000 claims yielding

$27M in savings

with a low appeal rate of 2.5% and virtually no overturned appeals (<.01%)

Recoup on Unnecessarily Paid Claims
With InformedDNA’s Post-Pay Pathway

Plans who fail to leverage the option to recoup on claims for genetic tests that do not meet standards of care or were egregiously billed may miss out on dramatic cost saving opportunities. Our Post-Pay solution offers:

Send historical claims data from within a lookback period (up to 7 years) for InformedDNA’s expert analysis and we’ll send you:

With our Payment Integrity Solution, your health plan can identify and recoup dramatic cost savings on claims for genetic tests that didn’t meet standards of care or were egregiously billed.

See How Our Post-Pay Payment Integrity Solution Helped One State Medicaid Plan

in total identified genetic testing claims overpayments
$ 0 M
identified from incorrect coding of only 3,000 hereditary cancer panels
$ 0 M
appeals uphold rate
0 %

How We Help Reduce Inappropriate Reimbursement

Analysis of 

Claims Data

Claims data is assessed to look for areas of highest spend and to determine which algorithms will be most impactful to reduce inappropriate spend.



Medical and reimbursement policies are analyzed to assess alignment with InformedDNA’s library of proprietary algorithms, which include both medical necessity and coding-based logic.



Selected proprietary algorithms capture specific tests and determine which CPT® codes on the claim should not be reimbursed or should be reimbursed at a lower level.

Appeals Support

(as needed)

In addition to providing support documentation materials such as our rationales and reference documents, we offer access to our clinical expert team for support through the entire appeals process.  

Interested in a Savings Opportunity Analysis?

Discover your savings potential with free, no commitment savings opportunity analysis. We’d love to show you our solution in action and explore how InformedDNA’s Payment Integrity Solution can help target significant savings and address common problem areas in your genetic testing claims management.

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