Genetic Testing: A real opportunity to reduce and improve prior authorization

Make progress in months, not years, by addressing the unique complexities of genetic testing.

Earlier this year, AHIP, BCBS Association, HHS, and most major health plans announced commitments to streamline and reduce prior authorization. In a rare moment of alignment, leaders across the healthcare ecosystem applauded.

Modernizing prior authorization will be a years-long undertaking, including platform upgrades, content re-architecture (especially to fuse clinical and reimbursement guidelines), and process change management. However, the recent announcements promise rapid results:

• Demonstrated reductions in medical prior authorization by next month 
• 80% of electronic prior authorization approvals (with all needed clinical documentation) answered in real-time in 2027

To meet these targets, plans need quick wins. Having developed all of the content and connectivity to manage outpatient laboratory testing (routine and advanced), Concert has found that genetic testing is a place where significant improvement to prior authorization is possible. While leaders may believe genetic testing, an area with complex coding, frequently changing guidelines, and complicated clinical reviews, is a bad place to start, the opposite is true.

Plans can reduce the burden of genetic testing prior authorization by 25-50% in a matter of months, not years, while simultaneously improving affordability, quality, patient access, and provider experience.

What is prior authorization for?

Patients and providers deserve to know, in advance, whether a healthcare service will be covered by insurance. Plans need to prevent unnecessary and dangerous medical interventions before they happen. Prior authorization meets these needs, in theory. In practice, the burden of the process often far outweighs the benefits. 

Prior authorization is best-suited to address medical interventions that are:

1. Expensive
2. Frequently misused 
3. Potentially harmful to the patient

Medical services that meet these criteria are good candidates to be on prior authorization. Major, non-emergency surgical procedures, for example. 

Some genetic tests do not meet any of these criteria, yet they remain on PA for unrelated reasons (e.g., variable coding obscures the service performed), which is one of several reasons it is a good place to focus improvement efforts.

Why focus on genetic testing?

To make meaningful improvements in prior authorization, leaders need to target areas that represent a high portion of authorizations and/or complex reviews, and which can be resolved without introducing waste or patient harm.

Genetic testing meets all of the above.

1. Genetic tests represent 15-20% of authorization requests but <1% of claims costs for many plans. This is a high-volume area where meaningful progress moves the needle.  One would assume it is equally large in claims costs. It is not. While leaders must always be careful to avoid waste when changing programs, this is one area where the risk of major problems is low.

2. Complex reviews, peer-to-peers, and appeals are frequent, yet inappropriate utilization for many tests is low. Clinical staff dread these cases. Coding is complex, multiple policies match for a single test, and the underlying evidence is constantly changing. Many cases escalate and become peer-to-peers (for which it’s often difficult to find the correct reviewer), sometimes just to determine what test was ordered and which criteria apply. This frustration masks the fact that, while some tests certainly are frequently misused and expensive, many are not. For example:

• High-volume prenatal tests such as carrier screening panels, single gene tests (CFTR, HEXA, SMN1/2), and non-invasive prenatal testing for aneuploidy are approved in 85-90%+ of prior authorization cases. 
• Hereditary cancer testing for cancer patients is used appropriately in the vast majority of cases. 
• Single gene rare disease testing is infrequent and reviews are long and burdensome, despite resulting in nearly 90%+ approvals. 
• Finally, many tests below the cost threshold to justify reviews can be removed with no meaningful impact to claims costs. While rare individually, the cumulative burden can be surprisingly high. As discussed later, any remaining misuse or waste can be managed in other, less burdensome ways.

3. Solutions are available and can go live quickly. This was not the case 10 years ago. Back then, there was no real answer to the growing challenges – inability to identify the test represented by non-specific codes and so-called “code stacking,” lack of clear medical necessity criteria for most tests, and frequent payment errors. Fast forward to today, solutions exist and are ready to go. 

Recognizing the opportunity, how can a plan achieve results quickly and plan for long-term, sustainable improvements?

Solutions that work

From Concert’s perspective partnering with health plans, UM partners, and payment accuracy solutions, here are key aspects of a true solution.

1. Identify the specific test and eliminate coding ambiguity. Countless hours are wasted by valuable clinical resources determining how a test should be coded, what test was performed, and what medical necessity criteria apply. This ambiguity can be nearly eliminated with transparent coding standards and a test identifier. Concert’s open test catalog ties each test to a 5-digit GTU® ID, appropriate coding, and a specific set of policy criteria.

• How to implement: Reimbursement policy. A simple 2-3 page policy requires the appropriate coding and test ID in prior authorization requests (and claims). As one medical director said, “Concert has, in a matter of months, eliminated genetic test panel coding problems that have existed for years.”

2. Perform reviews according to the test, not the code. A blocker for efficient reviews, and for removing many tests from prior authorization, is that tests and codes do not have a 1:1 relationship. Tests for one clinical indication share code(s) with another (e.g., hereditary cancer and somatic oncology tests). Multi-gene tests are often represented by more than one code. Concert’s up-to-date test registry, GTU®, and transparent clinical policy tie every test to a single set of criteria, enabling clarity on the front end of the auth process, speeding up reviews, and reducing escalations and errors, many of which occur in the process of determining exactly which service was actually performed.

• How to implement: Adopt policy tied to specific tests within the plan’s delegated entity, provider portal and/or review software. Vendor coordination can be complicated, but in this case, may be easier than expected. Concert’s content is built for delivery in any workflow. Existing integrations with UM partners enable consistency of policy and process in the solutions plans already know and trust. Lab providers are familiar with the process, too, having already agreed to Concert’s standards for existing plan customers.

Together, #1 and #2 reduce the overall prior authorization burden significantly for both the plan and providers by reducing the complexity of requests and the scope of services. Taking the strategy to the next level requires aligning with payment integrity.

3. Remove tests from prior authorization that can be managed with claim editing. With the above in place, plans can further limit the focus of prior authorization on expensive, frequently misused, and potentially harmful medical services. This means removing the 20-30% of genetic test volume that does not meet these criteria, and instead managing these as they do with other such services, claim adjudication and pre-pay editing. Concert’s claim editing recognizes the type of test represented by complex, multi-code claims and applies its library of edits, which are synchronized with the reimbursement and clinical policies above to ensure accurate, guideline-based payment instructions.

• How to implement: Claim editing integrations. Plans can move quickly on claim editing, working with the solutions they already trust. Concert’s flexible technology platform integrates seamlessly with the plan’s editor of choice, including existing partnerships with market leaders in the space. Customers often see claim edit savings in month 4 of implementation. Since Concert’s solution includes all outpatient laboratory testing (routine and genetic), the savings opportunity is often $15-25 PMPY.

Concert has seen firsthand it is possible to achieve dramatic improvements while simultaneously reducing overall medical costs, expanding access, and improving the provider experience. Health plan leaders should consider addressing genetic testing in partnership with Concert to make quick and lasting progress on prior authorization improvement efforts.