Managed Care Update

Anthem/AIM Responds to Queries About Its Pre-Approval Program

AFTER SEVERAL LABS SPOKE about the difficulties in working with the new Anthem/AIM Specialty Heath prior-authorization program for genetic tests, THE DARK REPORT sent questions to Anthem. Responses from Anthem/AIM were lengthy and have been edited to fit the available space:

Q: Is it true that labs cannot assist physicians in ordering tests through the Anthem/AIM program?

A: By having direct communication with the ordering physicians and their clinical team, we are able to determine not only the specific test they need for their patient but also the corresponding CPT codes in advance of the testing which makes the reimbursement process more efficient and cost effective.

Q: If it’s true that labs cannot assist their client physicians, doesn’t that make it difficult for doctors to get the tests they need for their patients and for doctors to understand the tests they’re ordering for their patients?

A: The Anthem Genetic Testing Solution promotes appropriate use and provides education that addresses the clinical and financial complexities of genetic testing. Physician reviewers and board-certified analysts are available for consultation with providers Monday through Fridays during business hours to discuss cases. We feel that utilizing genetic analysts who are independent of laboratories helps to eliminate any conflict of interest in the test selection process.

Q: Is it true that the Anthem/AIM process requires ordering physicians to request the prior approval and then send the patient away while waiting to get the approval?

A: The Genetic Testing Program has moved a traditionally manual, labor-intensive, and post-service process to a real-time automated system that delivers prior authorizations. It can also reduce the likelihood of errors in filling out paperwork, which adds to labor and time. For many tests, using the solution can cut down the average time for submitting and processing an insurance claim from days to minutes because the prior authorization review provides specific CPT code information to the insurer to facilitate the claim processing. The vast majority of genetic tests are currently ordered outside of the EHR process, either via a separate portal for the servicing laboratory or by completion of a paper requisition form. Integration into EHR systems is currently being explored by AIM for genetic testing and we hope to offer this option in the near future.

Q: Is it true that some AIM reviewers are unfamiliar with Anthem’s policies and so, while one reviewer will approve a test request, another reviewer will deny a request for that same test?

A: No. Case requests that meet clinical criteria are immediately approved. For a request that fails to meet evidence-based criteria at intake, our genetic analysts reach out to the ordering provider when alternate testing is available or additional clinical information may lead to approval. Through this exchange, the provider has an opportunity to provide additional clinical information necessary to adjudicate the request.

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