Overcoming the Challenges of Genetic Test Identification for Billing & Reimbursement

The Genetic Health Information Network Summit has become a forum for influential leaders across healthcare to articulate practical challenges and brainstorm solutions to enable precision medicine. One recurring theme of these events (summarized here) is the ambiguity in the systems used to identify genetic tests for billing, adjudication, and reimbursement.

It is no secret that the genetic testing market has grown quickly. This creates a number of challenges, one of which is that the consensus on how these tests should be billed has not kept pace. Coding variation, price variation, and time-consuming efforts related to billing and payment in this space remain high. These practical challenges limit the potential of genomic medicine.

With the goal of analyzing this problem and identifying practical solutions, Concert worked with fellow Summit organizers to host a webinar featuring leading experts in the space. Summarized here are key observations from the event and updates about cross-stakeholder solutions emerging from events like it.

Genetic test identification, coding, billing, and reimbursement is not a new problem, but it has evolved. Key updates and observations from the webinar include:

• The connection between payment and regulatory agencies has gotten tighter. Multiple organizations are impacted when test codes are established, so they need to collaborate.

• Coding has become granular and complex in response to a sharply rising genetic testing market. Without a taxonomy to organize and relate codes and code sets to one another, things can get confusing.

• Definitions and frameworks are not shared between clinicians, labs, and payers. With no shared language, consensus on how to make the system work lags.

• Not all challenges of genetic testing are about coding. Adjacent issues include finding scientific evidence or clinical practice guidelines to make a determination about a genetic test. And, what is “enough”?

A complete recording of the webinar can be found here.

These observations highlight challenges that are complex, and that cannot be solved by any one stakeholder. The intent of Summit events are to inform solutions that foster cross-stakeholder collaboration. One such solution, designed by Concert Genetics with input from Summit participants, may be of interest in the context of this conversation.

Laboratories and health plans have long needed an efficient method to agree upon how tests will be coded, priced, and covered. As multi-gene panels (billed with multiple codes) have proliferated, this need has intensified. Combing input from key stakeholders with its unique data and software, the team at Concert has designed an innovative approach whereby health plans establish a reimbursement policy that brings laboratories billing for genetic and molecular testing together with the health plan to agree to a set of test-specific coding recommendations.

In the case of this policy, the recommendations are generated by the Concert Coding Engine. This process aims to improve the clarity of linkages between the specific tests offered by laboratories and the billing codes associated with those tests, to bring consistency and reliability to the billing and reimbursement process. This clarity sets the stage for more predictable and efficient payment processes–benefiting all involved.

Launched in September 2019, the Concert Coding Engine is a data-driven coding tool for genetic testing, built to address transparency and efficiency gaps in the space. It aims to drive predictable reimbursement, consistent application of medical policy, and accurate determination of insurance coverage and price by following basic principles and assumptions:

• There should be one correct, agreed-upon way to code each genetic test on the market.

• Creating a set of unambiguous, standardized data requires a deep understanding of tests, codes, and data gaps.

• A unifying coding method should be integrated into the existing healthcare system, not created outside of it.

• A solution must be widely available, balanced with a business model to continue ongoing support of the tool.

The Coding Engine uses Concert’s detailed database as its ground truth for tests and test attributes. Driven by an algorithm, the Coding Engine follows a logic that maps tests to codes, building crosswalks between previously isolated and ambiguous data sets, pictured here.

Needless to say, more work remains to implement this (or any) solution on a market-wide basis. But the hope of the Concert team, in both helping organize the Summit and developing solutions like this one, is that the rate at which high-quality and high-value precision medicine is delivered through the U.S. healthcare system will continue to accelerate.

Challenges of genetic test identification for billing and reimbursement are persistent and evolving. Addressing them necessitates dialogue between stakeholders to build mutual understanding, definitions, and policy. The current system continues to function on fragmented, disconnected data that is inconsistently applied. Only when these data can be disambiguated, organized, connected, and integrated into existing systems can valuable insights be gained to bring transparency and improve patient outcomes through genomic medicine.

• Coding Variability in Genetic Testing provides a detailed view of how the extent to which similar genetic tests are billed using different combinations of codes, and how this affects test pricing. 

• A Coding Solution for Genetic Testing offers more details on the methodology and coding logic flow. Concert maintains a commitment to working with all stakeholders to improve the Coding Engine over time.

• GenomeWeb article on the coding variation and solution papers (subscription required)

• Whitepapers summarizing previous Genetic Health Information Network Summits

• Genetic test availability and spending: Where are we now? Where are we going? Health Affairs, Phillips KA, et al. 2018