Two Largest Payers Start Lab Test Pre-Authorization

Actions by UnitedHealthcare, Anthem bring genetic test prior-authorization to 80 million people

CEO SUMMARY: Once Anthem and UnitedHealthcare establish their respective genetic test prior-authorization programs, a new era for genetic testing will commence. The 80 million beneficiaries served by these two payers make up half of the individuals who have private health insurance. It is reasonable to expect that other health insurers will follow the lead of Anthem and UHC and institute their own programs to manage how physicians utilize genetic tests.

GROWTH IN THE UTILIZATION OF GENETIC AND MOLECULAR TESTS reached a tipping point during 2017. Faced with a swift increase in both the number of genetic tests available for clinical use and the volume of such testing being ordered by physicians, the nation’s two largest health insurers have taken tough action.

First to act was Anthem, Inc., which announced in April that it would institute its genetic test prior-authorization program on July 1. Just two months later, UnitedHealthcare made a similar announcement, saying Nov. 1 would be the start of its genetic test prior-authorization program.

Major Development For Labs

These actions are a major development for the nation’s genetic testing laboratories. UnitedHealthcare and Anthem each cover about 40 million beneficiaries. That means some 80 million individuals— about half of all Americans with private health coverage—will be in a plan with a genetic test pre-authorization requirement by year end.

The new policies at both companies could be problematic for labs offering molecular diagnostic and genetic tests. Typically, an insurer’s prior-authorization policy means that the insurer won’t pay the lab performing the test if the ordering physician did not get prior authorization first.

One aspect of UnitedHealth’s plan to require prior-authorization of genetic tests is that—when considered with its earlier decision to implement a pre-authorization and pre-notification policy in Florida—it makes it easier for health insurers across the country to institute their own prior-authorization programs.

These announcements could be positive developments for genetic testing labs that offer payers two things. One is they have good data on their genetic test’s accuracy that shows how physicians can use the genetic test results to improve patient outcomes. The second is prices that are reasonable for the clinical value that the genetic tests provide to physicians. These labs will have an easier time negotiating coverage and becoming in-network providers.

For lab companies that lack sufficient data on accuracy and clinical utility, genetic test pre-authorization requirements will make it tougher to win network status and get paid.

Two stories about these genetic test utilization programs follow. THE DARK REPORT provides the first details about UnitedHealthcare’s national genetic test prior-authorization program. One feature of interest is that UHC will have BeaconLBS handle some aspects of this program, which will be different than UHC’s laboratory benefit management program in Florida.

The story that follows presents an interview with a vice president of managed care at a major laboratory that provides genetic and molecular testing services. This lab executive discusses the issues his lab is having with Anthem’s prior-authorization program.

Problems with the Program

This is the second lab to provide THE DARK REPORT with inside information about the difficulties and problems that labs are encountering as they attempt to work with their client physicians and Anthem (along with Anthem’s AIM Specialty Health division which manages the program) to obtain prior-authorization for their genetic tests.

There is significance in the fact that, at nearly the same time, the nation’s two largest health insurers acted to implement genetic test prior-authorization programs. It shows that the utilization of these tests has increased to such an extent that payers recognize the need to better control how physicians use genetic tests.

What health insurers are about to discover, however, is the complexity associated with using any lab test to diagnose disease and guide decisions to treat. Early experience with the Anthem program indicates there are many issues to be resolved before acceptable normalcy is achieved.

United Healthcare Comments on Pre-Authorization Plan

IN RESPONSE TO QUESTIONS about the national genetic test prior-authorization program from THE DARK REPORT, a spokesperson for UnitedHealthcare said the following:

“Regarding UHC’s Molecular and Genetic Testing Notification/Prior-Authorization program, the UnitedHealthcare Lab Benefit Management pilot in Florida and the UnitedHealthcare Molecular and Genetic Prior-Authorization/Notification program are two different programs with different requirements.

“The Lab Benefit Management (LBM) program pilot is for commercial, fully-insured members in Florida, and includes 79 specific tests on the current LBM Decision Support Test list; among those, there are currently a few tests related to genetic testing, including cystic fibrosis and BRCA tests. This list will not change with the deployment of the Molecular and Genetic Prior-Authorization/Notification.

“Separately, the Molecular and Genetic Testing Notification/Prior-Authorization program is an online prior-authorization/ notification program. It will begin on Nov. 1, 2017 for UHC’s fully insured membership nationally outside of Florida.

“Regarding the laboratory benefit management program in Texas, UHC announced in January that it would delay the implementation of claims impact for the LBM program pilot in Texas. We have been closely monitoring progress of the pilot, giving us time to make refinements based on feedback from Texas care providers.

“Network physicians continue to have access to the physician decision support tool and are encouraged to use it when ordering decision support tests to continue building their familiarity with the lab ordering system. Care providers will be notified at least 90 days before the claims impact associated with the LBM program goes into effect,” concluded the UHC spokesperson.

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