Solution delivers payment accuracy and billing compliance in one of Medicare’s highest growth segments
NASHVILLE, Tenn. (Aug 26, 2021) – Concert Genetics has launched a genetic testing payment accuracy and compliance solution for Medicare and Medicare Advantage plans. The offering extends Concert’s innovative solution for commercial plans, providing unparalleled test identification, coding consistency, and automated determination of coverage to address both compliance and cost of care needs.
Payment accuracy in genetic testing is an urgent issue. In Medicare Fee For Service (FFS), which represents nearly 60% of the total Medicare beneficiary population, spending on genetic tests grew 47% annually from $289 million in 2015 to $1.36 billion in 2019, offsetting any reduction in laboratory spending expected to result from the Protecting Access to Medicare Act (PAMA), according to the U.S. Department of Health and Human Services Office of Inspector General. Meanwhile, the U.S. Department of Justice revealed more than $2.1 billion in losses due to fraudulent genetic testing billing, which it called “one of the largest health care fraud schemes ever charged.”
In addition to the cost of payment errors, complexity in genetic testing increases administrative expense and raises compliance risks. Research from Concert Genetics has shown multi-gene tests are often billed using 10 or more codes in thousands of combinations. With hundreds of genetics laboratories distributed across the country, Medicare Advantage plans must also contend with different coverage, coding, and billing guidance based on the Medicare Administrative Contractor (MAC) jurisdiction of the rendering laboratory.
“Genetic testing management is costly and administratively burdensome for Medicare plan administrators, and the cost is ultimately borne by the taxpayers they represent,” said Rob Metcalf, CEO of Concert Genetics. “By identifying specific tests, applying coding standards, and enforcing jurisdiction-specific coverage criteria, all in real time, Concert can deliver significant value to health plans and to the healthcare ecosystem.”
Concert’s Medicare solution leverages a unique combination of assets and capabilities that include:
- Genetic Testing Units (GTU), the market’s only comprehensive unique ID system for all 160,000 tests;
- Patented systems and methods to convert national coverage determinations (NCDs), local coverage determinations (LCDs), and billing and coding articles into data structures for automated enforcement; and
- Technology infrastructure that delivers real-time connectivity for pre- and post-payment review.
The solution is built and supported by a team of clinical genetics experts, data scientists, and software engineers. Concert’s Medicare solution is currently in beta with initial customers and will be generally available in early 2022.
About Concert Genetics
Concert Genetics is a software and managed services company that promotes health by providing the digital infrastructure for reliable and efficient management of genetic testing and precision medicine. Concert’s genetic testing management capabilities leverage a proprietary database of the U.S. clinical genetic testing market, market-leading expertise, and a technology platform that supports genetic test ordering, resulting, coding, coverage, and payment integrity.