Payers Turning to Automated Pre-Approval Systems for Genetic Tests

Payers are turning to automated systems for pre-approval of genetic tests as a way to contain costs and ensure proper utilization in the face of a dizzying number of news tests. UnitedHealthcare released a network bulletin in August 2017 announcing it will be implementing a national online prior authorization program for genetic and molecular testing performed in an outpatient setting effective Oct. 1 for its fully insured commercial members. Anthem Blue Cross implemented AIM Specialty Health’s Genetic Testing Solution July 1 for fully-insured and self-insured members, and will add national account members in 2018. The payers say that these automated processes can streamline prior authorization for providers, while laboratories are hopeful that automating the approval process can bring more transparency and predictability to coverage and reimbursement decisions, and potentially, can reduce the number of appeals for notoriously frustrating struggles for payment for molecular tests. While new for the diagnostics industry, the use of automated pre-approval systems or benefits management is not new for payers. The systems for genetic test management are analogous to efforts to rein in overuse of expensive imaging or prescription drugs. Payers say this solution is needed for molecular testing because managing costs and utilization is nearly […]