CEO SUMMARY: Since the July 1 launch of its prior-authorization program for genetic tests, Anthem and its subsidiary, AIM Specialty Health, have authorized few genetic tests, said a national lab. Lab directors say they have been unable to communicate with Anthem/AIM when client physicians order tests. Also, labs are unaware if Anthem has trained ordering physicians in how to use the new system. Given that Anthem insures 40 million Americans, these problems may be a challenge for many genetic testing labs.
FOLLOWING THE JULY 1 START of Anthem’s program to require pre-authorization of genetic tests, more genetic testing labs report trouble getting pre-approvals and payment for tests.
In response, some genetic testing labs have taken their concerns to the American Clinical Laboratory Association, although ACLA would not comment to THE DARK REPORT as to whether it is preparing a response to send to Anthem and its subsidiary, AIM Specialty Health. AIM runs the prior-authorization program that began July 1 in the 14 states where Anthem operates.
Anthem is the nation’s largest health insurance company, insuring almost 40 million Americans. Thus, any problems in obtaining pre-authorization and payment for genetic tests will affect many clinical lab companies.
To date, complaints about the program have come from sources who asked to remain anonymous. A vice president for one large genetic testing lab said Anthem has authorized few specimens from requests from ordering physicians. Also, in some genetic test orders that Anthem has approved, Anthem or AIM issued a prior authorization but used the wrong CPT code because the ordering physician didn’t know which code the lab would use.
Labs Have No Role
“This lack of communication between the physician, the lab and the insurer is required under the protocols Anthem and its subsidiary, AIM Specialty Health, have adopted,” stated the lab VP. Also, the staff in his laboratory was unaware if Anthem/AIM had trained any ordering physicians in how to use the new system, he added. Anthem/AIM responded to this and other complaints.
The problem this vice president described is similar to that of another laboratory director at a different genetic testing laboratory who also was frustrated when working with Anthem/AIM’s genetic test prior-authorization program. (See TDR, Aug. 7, 2017.)
“We are accustomed to dealing with prior-authorization requirements, especially for genetic tests,” commented that VP in an interview with THE DARK REPORT. “What makes the Anthem/Aim program different is that they have so far prevented us—as the ordering laboratory—from filing the prior-authorization request on behalf of the referring provider. That is one aspect of the program that we would like to see changed.
Too Little Time for Approval
“Another problem we’re having is that the ordering provider has a 48-hour period to get the prior authorization,” he said. “Essentially, it means the system Anthem/AIM has established is different from the way most payers require approval.
“Let me clarify that a bit. In the lab world, the date of service is usually equal to the date of collection,” the VP said. “So, if the collection is on Monday, the laboratory typically does not have the specimen until Tuesday. At that point, the laboratory can call the ordering provider to explain that the physician submitted a specimen without the necessary prior authorization. The lab also will ask the provider to get the prior authorization and send the documentation to us.
“By the time the physician gets around to requesting the prior authorization, the 48-hour window usually has expired,” he explained. “In a perfect world, the physician would obtain prior authorization before collecting the specimen, but that doesn’t work well within the workflow of physicians’ practices.
Lab Bears Financial Liability
“If a physician does not obtain the prior authorization, then our lab bears the financial liability of an unpaid claim after performing the genetic test that the physician requested,” he added.
“Other health plans and lab benefit management companies allow labs to file for the prior authorization on behalf of the ordering provider and to use what we call the retro prior-auth period,” he said. “Typically, the retro period is between eight and sometimes 30 days, depending on the payer. Sometimes, a lab needs all that time to get the necessary information. That is why the 48 hours under the Anthem-AIM program is much more frustrating—especially when compared with our experience with other health plans.
“When the 48 hours ends, we are in a quandary,” he added. “That’s when our lab faces the question of whether we should destroy the patient’s specimen or run the test.
“Destroying the specimen could interfere with patient care, depending on the purpose for which the genetic test is being ordered,” observed the lab VP. “But if our lab runs the test, there’s a strong likelihood that we won’t get paid.
“We could fight it on appeal, which is unduly expensive because we have to pay staff to file the appeal,” the VP said. “And usually, the first appeal is denied and so we have to go to a second level of appeal.
Lengthy Process for Appeals
“The appeals period can vary but typically it will take 30 to 60 days to get through the initial denial,” he added. “Then, our lab may need another 30 to 60 days for the second level of appeal. So our lab is looking at easily six to nine months to work through the process of getting a claim paid. And sometimes it doesn’t even get paid on appeal.”
Another problem is that, as of this time, physicians serving Anthem patients have yet to be trained on how to use the prior-authorization system. Early in July, the VP’s lab asked Anthem/AIM to provide the training materials that it sends to its physicians to explain how to use the new prior-authorization program.
“What they sent were two provider newsletters of about 12 pages each. In the middle of the newsletter there is a small three-paragraph section about AIM’s prior-authorization program for genetic tests.
“That would suggest there wasn’t much focus on provider education and I am unaware of any other effort by Anthem to educate the provider community,” the VP said. “When I asked if Anthem would do any further education of providers, I was told that they recognized the need for additional training.”
At that point, the VP was surprised to learn that Anthem/AIM wanted his lab to give it the names of all the physicians submitting tests without first getting the required prior authorization. “That request is particularly problematic because it puts a burden on us as a laboratory to report physicians to health plans,” he commented.
Lab Asked to Name Names
“We would rather see Anthem look at claims that ultimately get denied because of no prior authorization and use that as their roster for physician education,” he noted. “That would keep our lab out of an uncomfortable position and we would not need to pay staff to develop the report.
“All of this trouble is surprising because we have a national agreement with Anthem, so we are in-network in all of the 14 Anthem states, except for two where we’re excluded due to a prior contractual arrangement,” he said.
“After speaking with people at smaller labs (and even some of the larger labs), no one tells us they are having any success with the Anthem/AIM prior authorization program,” the VP reported.
Asked how many tests his lab has submitted to Anthem/AIM under the new-prior authorization program, the VP could not say because the lab has been unable to use the Anthem/AIM portal.
“As an in-network lab provider, we are not able to log into the Anthem/AIM portal to initiate the prior authorization,” he explained. “Nor will they speak with us by phone. When we call them, they’ll answer. But once they find out who we are, they inform us that they will not speak with us about issuing a prior authorization. The whole system is extremely frustrating.
Rely on Ordering Physicians
“The end result is that our lab must rely on its ordering physicians to submit the prior-authorization request and ensure that the request gets approved in time,” added the VP. “If not, our lab risks performing genetic tests for which it will not get paid.
“Our laboratory is in a difficult position,” he commented. “For certain genetic test requests, we can wait because these tests are not critical to medical care. But, of course, other genetic tests are critical to medical care and that puts our lab in a difficult position because—at the very least—we are faced with the financial liability of an unpaid claim.
“But if we choose not to run the genetic test, then our lab faces the potential of some sort of lawsuit for malpractice,” he added. “Stated another way, if our lab does not run the genetic test because the physician did not send us the prior authorization with the lab test order and the patient is denied necessary care or treatment, then who’s to blame? Naturally, we feel compelled to do the right thing for the patient and rendering the genetic test results is the right thing,” he concluded.
Will System Be Improved?
The issues encountered by this lab when working with physicians and Anthem are consistent with the issues described in an earlier interview published in the previous issue of THE DARK REPORT. Both labs are devoting considerable resources to understand the new Anthem/Aim genetic test prior-authorization program. If other lab managers have experiences to share, they can contact our editor.