CEO SUMMARY: With programs now at the nation’s two largest insurers, is it possible to argue that prior-authorization is going mainstream? Some observers say, yes, as THE DARK REPORT predicted. What is certain is that starting Nov. 1, UnitedHealthcare is requiring prior authorization for genetic and molecular tests for its fully-insured commercial members nationwide. That comes just 12 weeks after Anthem started its genetic test management effort on July 1 in all 14 states where it operates.
ONE MONTH AFTER ANTHEM, INC. announced it would require physicians to use its genetic test management program, UnitedHealthcare said that, effective Nov. 1, it would require physicians to get prior authorization when ordering genetic and molecular tests for UHC members in fully-insured commercial plans.
With this decision, the nation’s two largest health insurers have taken an important step to manage utilization of genetic tests. These actions may encourage other private payers to initiate their own programs aimed at managing how physicians order genetic tests.
Labs Asked to Register
In a letter, UHC asked labs to register by Sept. 15 to be included in “our new genetic and molecular lab testing notification/ prior-authorization program.” Thirty days before the program begins on Nov. 1, UHC will make training and more information available at UHCprovider.com, the letter said.
The letter described how labs and physicians would participate, stating: “Starting Nov. 1, 2017, a new online notification and prior-authorization process will be implemented for genetic and molecular lab tests for UnitedHealthcare commercial benefit plan members.”
Beacon Laboratory Benefit Solutions, Inc., a lab services management company that is a subsidiary of Laboratory Corporation of America, is working with UnitedHealthcare and will register participating labs for the program and manage the online notification/prior-authorization request system, the letter said.
BeaconLBS manages a prior-notification program for UHC’s HMO members in fully insured plans in Florida since 2015. Physicians and clinical labs have criticized that program for being difficult and time consuming and for failing to integrate with many common EMR systems, forcing ordering physicians to enter test orders and results twice.
UHC’s letter continued: “We encourage all labs participating in United-Healthcare’s network to register. BeaconLBS has created a streamlined prior-authorization process for care providers that will leverage UnitedHealthcare’s clinical policy requirements for all coverage determinations.”
About BeaconLBS, a spokesperson for UHC said, “Beacon will collect the information for prior authorization, but UHC will do all of the reviews and decision making.”
The test list is comprehensive. UHC said that, “Physicians ordering tests will initiate prior authorization through BeaconLBS when ordering tests such as BRCA1/2, hereditary cancer panels, pharmacogenetic panels, tier 1 and 2 molecular pathology procedures, genomic sequencing procedures, multianalyte assays with algorithmic analyses that include molecular pathology testing, and tests with the following CPT codes: 0001U; 0004M to 0008M; 81161 to 81421; 81423 to 81479; 81507 and 81519; and, 81545 to 81599.”
A source at a large clinical lab who asked not to be named said these tests are among those for which UHC currently requires labs or physicians to get pre-approved. Therefore, the listed tests should not be much different from current practice, he added. The big difference will be how well UHC works with BeaconLBS on the data collection effort.
UnitedHealthcare’s letter continued: “The ordering care provider will specify the test name and select the testing laboratory. To give ordering care providers the ability to select your laboratory for genetic and molecular tests when the requirement starts on Nov. 1, you need to register with BeaconLBS by Sept. 15 by going to BeaconLBS.com, login, and lab login.”
Labs Asked to Register
Lab managers should note that, after Nov. 1, payments will be authorized only for those genetic and molecular tests performed by labs registered with BeaconLBS as part of the genetic and molecular lab testing notification/prior-authorization program.
“BeaconLBS will need the following information to complete your registration for all applicable testing to support accurate and timely prior authorization and claims payment: the test name, unique test identifier, all associated CPT codes and units billed,” the letter said. Also, labs will need to supply their National Provider Identifier and CLIA numbers and a valid email address for the lab.
Florida Program Different
The lab director emphasized that this new nationwide genetic and molecular test pre-approval system will be different from the current prior-notification program BeaconLBS uses in Florida.
“It’s clear that UHC wants to make the prior-authorization decision more efficient because they’re saying Beacon can make that decision quickly,” the lab director said. “If I called UnitedHealthcare today and requested prior authorization for BRCA testing, they would ask for medical records and this and that. But, with the design of this nationwide program, they say the BeaconLBS system can do this faster.
“Both UHC and BeaconLBS have electronic portals and I’m familiar with UHC’s, which is quite basic,” he added. “I’m not at all familiar with the planned Beacon prior-authorization portal. But I do know that it will be different from the portal BeaconLBS uses in Florida.
“In fact, it has to be different because the program in Florida is a prior-notification program and the nationwide program is a prior-authorization program,” he explained. “And, it’s different because UnitedHealthcare said it will make the decision on genetic and molecular tests and Beacon’s role involves registering labs and collecting the prior-authorization data from labs and physicians.”
Other lab executives point out that UnitedHealthcare is not leaving much time for physicians to sign up by the Sept. 15 date. They also want to know what recourse a lab would have if it performs a genetic test, but later learns the physician did not obtain the required pre-authorization.