Issues Encountered with Anthem’s Pre-approval

Laboratories, physicians report challenges with Anthem’s genetic test pre-approval program

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CEO SUMMARY: Since Anthem and AIM Specialty Health began a prior-authorization program for genetic testing July 1, a Northeast lab has not had any genetic tests approved through the new system. Physicians told the lab that the steps required for prior authorization were disruptive. Those doctors who regularly order genetic tests had not been trained in how to use AIM’s genetic testing pre-authorization system and said their training was not scheduled to begin until this month.

LABORATORIES OFFERING MOLECULAR AND GENETIC TESTS have keen interest in the genetic test pre-authorization requirements instituted by both Anthem and UnitedHealthcare in recent weeks. At stake is access to Anthem’s 40 million beneficiaries and the 31 million beneficiaries insured by UnitedHealthcare.

Physicians and genetic testing laboratories share similar concerns about genetic test pre-authorization requirements. They want the procedures and tools that health insurers use in their genetic test pre-authorization programs to be simple to use, speedy, and consistent with established clinical guidelines for genetic tests. Yet, so far, lab directors said, the Anthem program fell short of these goals.

In April, Anthem announced its pre-authorization program—called The Genetic Testing Solution—for genetic tests. AIM Specialty Health, a division of Anthem, administers the program. (See TDR, June 26, 2017.)

Just weeks later, on June 30, UnitedHealthcare said it would be launching its own pre-authorization initiative for genetic tests. UHC has since said it would delay implementation of that program until Nov. 1.

The actions of the nation’s two largest health insurers confirm a prediction THE DARK REPORT made that health insurers’ efforts to require pre-authorization of genetic test orders would soon be a mainstream requirement. The similar actions by Anthem and UnitedHealthcare means that by November, 71 million members will be subject to pre-authorization requirements whenever their physicians order genetic tests for them.

Aiming for Ease of Use

Following Anthem’s announcement in April that it would launch a genetic test pre-authorization program, THE DARK REPORT interviewed Karen Lewis, Director for AIM’s Genetic Testing Solution.

Anthem and AIM knew of the need for its processes to be easy for physicians to obtain pre-authorization, she said. A benefit to the lab that performed the genetic test is that pre-authorization would allow the lab to know—in advance of service—that its claim for that genetic test would be paid, she added.

To assess how AIM’s Genetic Test Solution is functioning in the early weeks of its launch, and whether it is meeting the needs of physicians, labs, and patients, THE DARK REPORT has heard from a number of genetic testing labs.

A Challenging Process

Executives at several genetic testing lab companies said the program’s launch has not gone smoothly in its first month of operation. In an interview with THE DARK REPORT, representatives of one genetic testing lab described Anthem’s new pre-authorization process as needlessly complex and difficult to use.

The representatives of this lab, who asked to remain anonymous, described two issues of concern. First, since the program began July 1, the lab has not had any genetic tests approved through the prior authorization process. Second, physicians are asking the lab to participate in the prior authorization program, but Anthem and AIM have said only physicians can use the pre-approval program. Also, physicians told the lab that doing the prior authorization for lab testing is disruptive. For example, one physician’s office needed to call AIM and the lab multiple times to receive approval for what was a simple process previously, the lab representatives said.

Physicians who regularly use the lab’s genetic tests had not been trained in how to use AIM’s genetic testing pre-authorization system, they added. Physicians told them AIM had not scheduled such training to begin until this month (August), more than 30 days after the pre-authorization requirement became effective.

For this national genetic testing lab company, the AIM program has not improved efficiency and is the source of much frustration. The lab representatives added that other lab test management programs allow labs to submit the prior authorization forms for the physicians’ office, the lab’s representative said.

Keep in mind that the comments in this article are based on one lab’s experience only. Other labs may have had a more positive experience. THE DARK REPORT is interested in interviewing lab directors and other staff in genetic testing labs who have had experience with Anthem’s Genetic Testing Solution.

The experience of this genetic lab company is typical, however, when health insurers and health systems attempt to use software algorithms to manage lab test utilization of physicians.

The VP of sales for the national genetics lab described the Anthem program as having similar issues as those identified when UnitedHealthcare implemented its laboratory benefit management program in Florida. BeaconLBS, a subsidiary of Laboratory Corporation of America, manages that program. Physicians and lab directors complained about that program, which began in 2015, saying it was complex, time-consuming, and difficult to use. Just a few of the 79 lab tests requiring pre-notification or pre-authorization in the BeaconLBS system are genetic in nature.

“For the Anthem program, the physician must enter AIM’s website, set up an account, become familiar with the different testing protocols, select the genetic test, and then answer a series of questions before the system issues an approval. Physicians have told the lab that the questions do not always apply to the genetic tests being requested.

Unrelated Questions

“The questions are more complex and relate to the specific process the lab undertakes for the testing and they require the physician to list all the genes being tested along with the CPT and diagnosis codes,” said the sales VP. “It’s basically a manual administrative process that physicians must complete to get the genetic test order authorized. Once that step is done, Anthem will pay the lab performing the genetic test.”

Calling an insurer for approval can delay patient care and inconvenience the patient. This can affect patient satisfaction scores negatively, the sales VP noted.

“For most labs today, physicians draw the patients’ blood and send it into the lab the same day,” he said. “The lab handles the specimens and begins the prior authorization process.

“Under the new program for Anthem and AIM, the physician sends the patient away from the office, begins the steps for prior authorization, and hopes to get all the information needed for pre-approval before the patient returns for specimen collection,” the sales VP said. “The window of time for appropriate testing varies, thus physicians are concerned that they will not have the approval before it is needed.

New Administrative Burden

“Not only does the process create a new administrative burden for the physician, but the steps of first placing the test order and second receiving the results happen outside of the physicians’ electronic health record systems,” he continued. “That means the pre-authorization is not part of the normal electronic flow of lab-test ordering for the physician. It also means the new system creates additional work because doctors are entering the same information twice.”

This lab’s case manager works closely with physicians trying to obtain authorizations on the lab’s behalf because the lab staff cannot be involved in ordering, she said. Having the physician get the authorization slows the ordering and can affect patient care, noted the lab’s case manager.

“By adding days until the genetic test actually gets run, the patient may need to wait four to six weeks before getting the results,” she added. “If we’re talking about cancer genetics, that could be a significant delay that would affect medical management and perhaps a pending surgery.”

Another problem the lab has is a lack of understanding among AIM staff of Anthem’s medical policies, the case manager said. “Recently we’ve seen some denials where AIM is misinterpreting Anthem’s medical policy and denying tests that clearly should be approved. At the same time, other patients receive approval presenting the same medical data to another AIM reviewer,” the case manager said. “As a lab, that’s frustrating.”

Anthem Seeks End to Inappropriate Testing

WHEN ANTHEM AND AIM SPECIALTY HEALTH ANNOUNCED their pre-approval program for genetic tests in April, the companies cited research showing that 30% to 50% of such tests may be ordered inappropriately.

In addition, the companies said physicians today can choose from among more than 70,000 genetic testing products and that clinical labs introduce an average of 10 new products every day. This causes health insurers and providers to struggle to keep pace with the demand for complex and costly genetic and molecular assays. AIM Specialty Health, a division of Anthem, is managing the program.

Physicians in all 14 states where Anthem operates are required to follow Anthem’s protocols for ordering any of the tests listed in its 45 genetic testing guidelines. “The Genetic Testing Solution promotes appropriate use and provides education that addresses the clinical and financial complexities of genetic testing,” Anthem Blue Cross said last week in its press release announcing the program.

In addition to California, Anthem’s divisions serve members in Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia, and Wisconsin.

The program affects Anthem members who have insurance through their employers in fully-insured and self-insured companies. Anthem plans to add its members in national accounts next year, Anthem Blue Cross said.


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