No World Borders, Inc. announced that genetic test billing expert Michael F. Arrigo published findings regarding insurance utilization, medical coding, and medical billing of genetic tests. He also shares findings regarding fraud waste and abuse in genetic testing.
INTRODUCTION
Genomic medicine is revolutionizing medicine and creating new opportunities for predictive diagnosis and precision medicine. As a result, laboratory tests are now the highest-volume medical intervention.1 Over 6.5 billion laboratory tests are performed annually in the U.S. Diagnostic testing may impact greater than sixty-five percent (65%) of clinical decisions.2 Yet, overall mean rates of case specific over-utilization were 20.6%, and case specific underutilization was 44.8%.3
CHALLENGES
There have been concerns regarding the cost of testing. Yet, the healthcare industry has not developed the tools to evaluate the medical necessity, efficacy, and reasonable costs fairly. Furthermore, there are ethical and privacy concerns regarding genetic testing. The Federal Genetic Information Nondiscrimination Act (GINA) prevents insurers from discriminating against patients. There are state laws that add further protections to prevent genetic discrimination by insurers, but this area is rapidly evolving.
FINDINGS AND CONCLUSIONS
Among his findings are:
- The rate of innovation in genetic testing means that more tests are available daily than the health care industry can operationalize for efficacy data, care delivery, and insurance coverage
- The Medical CPT codes and insurance efficacy data do not match the number of tests.
- Sometimes, a one CPT code to many tests or test panels creates complexity and lack of specificity. As a result, fraud detection requires analytics and patient chart reviews.
- Medicare Local Coverage Determinations (LCDs) do not cover all potential tests.
- Because of a mismatch between existing regulations and a lack of codes and policies, some testing companies are using improper billing practices leading to fraud, waste, and abuse. This results in higher health care costs for insurers and insured beneficiaries.
- Access to diagnostic testing is essential for early detection. Still, fraud increases the cost of insurance, reduces access to care, and increases utilization while causing underutilization for some patients who need the tests the most.
- Patient identification errors when reporting test results have led to results being reported for the wrong patient, leading to medical decision-making errors and adverse events.
- As a result, a genetic test medical cost expert who understands Utilization Management, Clinical Policies, Medicare Local Coverage Determinations (Medicare LCDs), and Commercial Insurer Medical Necessity Policies is invaluable in cases where genetic testing costs are being evaluated or litigated.
About Michael F. Arrigo
Michael F. Arrigo was recently quoted by an investigative journalist at The Capitol Forum regarding genetic testing. He is managing partner of No World Borders, a company of experts in healthcare data, regulations, and economics.
No World Borders In the News / Medical Billing Expert Witness
1 Medical interventions measures to improve health or alter the course of an illness and can be used to prevent, diagnose, and treat disease.
2 2019. Kathryn A. Phillips Patricia A. Deverka The Emerging Use By Commercial Payers Of Third-Party Lab Benefit Managers For Genetic Testing https://www.healthaffairs.org/do/10.1377/hblog20191021.563154/full/
3 2013. The Landscape of Inappropriate Laboratory Testing: A 15-Year Meta-Analysis Ming Zhi, Eric L. Ding, Jesse Theisen-Toupal, Julia Whelan, Ramy Arnaout
Published: November 15, 2013 https://doi.org/10.1371/journal.pone.0078962
SOURCE No World Borders, Inc.