Genetic Test Pre-Authorization Goes Mainstream

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IT IS ALWAYS A BIG DEAL WHEN ONE OF THE NATION’S LARGEST HEALTH INSURERS TAKES A MAJOR STEP. That is certainly true of Anthem’s decision to launch a new program that requires physicians to obtain pre-authorization when ordering genetic tests for its members.

THE DARK REPORT is first to report this news to the clinical laboratory industry. The nation’s largest insurer, Anthem has health plans in 14 states that cover approximately 40 million Americans. Thus, this requirement will affect many labs offering genetic tests.

Moreover, whenever an industry leader adopts a major policy, it is not long before most competitors take similar actions. Thus, we can expect that, once Anthem’s genetic test pre-authorization program is in place, other health insurers will introduce their own pre-authorization programs. That will further bring genetic test pre-authorization into the mainstream.

As this happens, the environment will become more challenging for the nation’s genetic testing lab companies because health insurers will want solid evidence that these tests measure biomarkers accurately and that they offer clinically useful results, meaning physicians can use these test results to change patient care and generate improved outcomes.

To help you understand why Anthem is going down this path and how it will proceed, we present an exclusive interview with the executive responsible for implementing this program. We also include a list of the 45 specific genetic tests that will require pre-authorization.

Anthem is not the first to take this action involving genetic tests. In 2013, Cigna pioneered this approach and has expanded the list of genetic tests requiring pre-authorization since then. (See TDRs, Aug. 19, 2013, and Dec. 15, 2014.) Blue Cross Blue Shield of South Carolina (an independent Blue that Anthem does not own) is another health insurer that has a genetic test pre-authorization program in place. (See TDR, Oct. 26, 2015.)

Genetic testing companies and labs in academic medical centers labs would be well-advised to prepare for tougher new requirements for genetic testing. To do so will involve taking greater care to gather the clinical data to support claims of analytical accuracy and how these lab test results affect patient care.


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