As laboratory testing reimbursement cuts continue, laboratories look to add genetics and molecular testing. The annual cuts from CMS and commercial payers are the driving force behind laboratories wanting to create a new revenue stream. There are more than 150,000 genetic tests on the market today. According to the U.S. Department of Health and Human Services, procedure codes rose greater than 160 percent, Medicare payments quadrupled from 2016-2019, and the number of providers ordering tests doubled.
Understanding Genetics Revenue Cycle
If your lab is contemplating the idea of genetic testing as part of your laboratory services, then you’ll want to take the time to understand the revenue cycle process before submitting insurance claims. Bear in mind medical necessity differs from one jurisdiction to another. Since there are only a few national policies for genetics reimbursements, it’s vital to research the guidelines for which payers will reimburse and under what conditions. A good example, make sure the population in your area is participating in plans that will pay. If you are out of network, what is the policy for genetic reimbursements? If in-network, what is the contracted rate? Investigate which plans require prior authorization or if plans utilize a laboratory benefit management programs. Commercial payers and Medicaid have different policy rules based on each test billed.
Genetic testing is growing in popularity, so are multiple gene test complexities. Multiple gene panels currently are based on what particular genes are analyzed and the techniques used. To bill genetics a tiered and applicable CPT codes to determine tier 1 and 2, testing panels are identified. The professional CPT coding index guidelines categorize the two tiers. Tier 1 is the most common tests ordered. Specific sequence targets, for example, BRCA, KRAS, and JAK2. Tier 2 are genetic tests not found in tier 1. These tests are customized panels created to fit specific sequences.
Barbara Shaub, Director of Revenue Cycle, RCM Enterprise Services, explains:
“You want to take the time to evaluate your testing needs. What tests are suitable for the best patient outcomes? Often healthcare providers order tests that may not be clinically significant or are not targeting the patient’s condition. This results in increased costs and unnecessary testing. We work closely with laboratories that want to invest in genetic testing and provide them with billing guidelines in their area. It helps them to understand the fundamentals of billing genetics and test set-ups.”
Trends and Tips You Should Look for When Billing Genetics
Submitting accurate ICD-10 codes is first to ensure compensation. Next step, complete the documentation required. Confirm the test panels ordered support the condition being performed. Accounts receivable reporting is a good way to check for denial patterns and trends as to why a claim is denied. Denial management is the key to successful reimbursements. Doing your research before implementing genetic testing will help you, in the long run, to understand how to create appropriate testing panels and what insurance will compensate for the testing you want to provide in your area.