Getting Paid for All Your Lab's Genetic Test Claims—What’s Changing, What’s Not, and What’s Working Best

Product Cover Prop_Special Report_Getting Paid for Genetic Test Claims-1



"The clinical lab industry has a new engine of growth—companies that specialize in genetic testing. Starting about six to eight years ago, the number of new genetic test company start-ups began to increase. Many of these new enterprises have proprietary or patent-protected genetic tests. For genetic tests, clinical labs need to understand the ins and outs of what it takes to get reimbursed for testing they provide."

Robert Michel
Editor-in-Chief, The Dark Report

Getting paid for genetic test claims remains the single biggest challenge for all clinical laboratories and anatomic pathology groups

Genetic testing is the fastest-growing sector of clinical laboratory medicine. Over the past decade, the intersection of policymakers, entrepreneurs, investors, and healthcare leaders has advanced innovative methods of predictive, diagnostic, and research-related forms of advanced molecular and genetic testing.

However, genetic testing laboratories face an ongoing dynamic business landscape where their tests will be questioned more often than not—at the same time as record-level payer spending occurs in some testing categories. Commercial payers, in particular, dictate strict coverage criteria for how they accept and pay for genetic test claims, which can cost thousands of dollars per test.

The good news? The business of genetic and molecular testing is robust for labs—even with these revenue cycle vulnerabilities. Every clinical laboratory and genetic test company can significantly increase net collected revenue and reduce denials, but only if their team understands how to meet requirements for clean claims.

Authored by four industry experts, this Dark Intelligence Group special report, State of the Genetic Testing Marketplace, provides guidance and best practices for clinical laboratories and anatomic pathology groups to gain a critical understanding of the genetic testing landscape.

Content and Features

State of the Genetic Testing Marketplace: Getting Paid for Genetic Test Claims—What’s Changing, What’s Not, and What’s Working Best provides independent laboratory leaders, laboratory-developed test developers, and hospital and health system leaders with in-depth, straightforward analysis and guidance to help understand the genetic testing landscape and how to navigate it.

The following chapters include engaging, down-to-earth information complete with tables, illustrations, and summaries of key takeaways:

INTRODUCTION: Three Factors Complicate Reimbursement for Genetic Test Claims

CHAPTER 1: Explosive Growth of Genetic Testing Opportunities for Labs: Scrutiny and Analysis of Molecular Test Spending in the U.S.

CHAPTER 2: Understanding and Managing Complexity and Ambiguity: The Genetic Testing Landscape Explained

CHAPTER 3: What Labs Need to Know About the Payer Framework of Policy and Coverage For Genetic Tests

CHAPTER 4: Understanding Claims-Side Issues Under the New Rules of Genetic Testing Claims Management

CHAPTER 5: A Review of Molecular Pathology and Genetic Test Coding and Billing Considerations

CHAPTER 6: Lessons Learned from Federal Enforcement Actions Directed at Genetic Testing Labs and People Behaving Badly on Their Behalf

CHAPTER 7: Best Practices for Meeting the Challenges of Getting Paid for Genetic Test Claims

Expert Authors

Bruce Quinn
Ron Metcalf
Heather Agostinelli
Ann Lambrix

Bruce Quinn, MD, PhD

Bruce Quinn Associates LLC

Rob Metcalf

Chief Executive Officer
Concert Genetics

Heather Agostinelli

VP of Strategic Revenue Operations

Ann Lambrix

Vice President of RCM Consulting
Lighthouse Lab Services—Vachette Pathology

Takeaways & Benefits

This special report will educate your entire team and lay the groundwork for improving your genetic test claims reimbursement. Through reading this special report, you will:

  • Gain a better understanding of the genetic testing marketplace and landscape.
  • Develop business and operational strategies to maximize their investment in genetic and genomic testing precision medicine initiatives.
  • Obtain successful coverage decisions for their genetic tests by understanding how to meet a payer’s coverage criteria.
  • Work with individual health plans to become an in-network provider.
  • Learn from recent genetic testing fraud enforcement actions, such as Operation Double Helix and other crackdowns.
  • Discover why “benefit investigation” is already a huge factor as consumers seek the lab with the lowest genetic test price before they agree to be tested.