The effort required to manage genetic testing can seem endless, despite the fact it is a small area of spend. Market trends suggest this will continue. Volumes are growing, and so is the complexity of medical policy, coding, and utilization review. Several factors make this area unique:

  • More tests: 150,000+ genetic tests are on the market, compared to 10,000 in 2012, with limited ability to compare quality and value.

  • Complex claims: On average, 6.9 codes are billed to represent a single genetic test.

  • Cumbersome policies: Up to 1,000 pages of medical policy offer no clear answer for many tests.

Health plans that rely on outdated management approaches are experiencing a growing volume of prior authorizations, denials, reviews, and appeals – all made more complex by multi-gene panel tests with multiple billing codes. The result is waste, variable quality, and frustrated members, providers, and medical directors.