| R. Lewis Dark:
Molecular Code Stacks Now in the Payers' Bull's Eye
LIKE A STEAM BOILER READY TO EXPLODE FROM TOO MUCH PRESSURE, the nation's
health insurers have reached a point of no return on the subject of codestacked
claims for genetic testing and molecular diagnostics assays. Simply
put, payers are ready to tackle this sensitive issue.
Payers have reasonable questions about this type of clinical lab testing. Is it
sound practice to accept a claim for a laboratory test that does not identify the
clinical function of the diagnostic test? Equally relevant, why would labs
expect any payer to reimburse a laboratory test claimthat didn’t include information
necessary to identify that the molecular lab test is an appropriate clinical
procedure for the patient, given the specific health conditions the
attending physician is investigating?
Code stacking claims for genetic tests and molecular assays generally fail to
give payers useful information on both of these points. If this were your company,
and you were paying the bills, would you consider it good business to
accept these claims without challenge and issue payment? Wouldn't you want
to understand the clinical purpose and the clinical efficacy of these genetic and
molecular tests?
How did health insurers and the clinical lab testing industry get to this
point? The process of creating new CPT codes probably has a role in this story.
After all, we are more than a decade into the genetic testing era and the CPT
coding system is woefully behind today's molecular testing marketplace.
Most pathologists have heard the comment attributed to Otto von
Bismarck, a German politician of the 19th Century, who said: "If you like laws
and sausages, you should never watch either one being made." Some have
hinted that the process and politics of updating the CPT coding system would
probably fit Bismarck's description of law- and sausage-making.
The fact remains that current CPT codes do not help labs describe all the tests
they perform in support of clinical care. Nor do health insurers get the precise
information they need when code-stacked claims for molecular tests are submitted
for reimbursement. It is no surprise, then, that, as of March 1, 2012, one
important Medicare carrier is stepping up with a plan to provide an interimsolution
to the recognized inadequacies of existing CPT codes for genetic andmolecular
tests. It may not be perfect, and it is likely to be criticized and even challenged
in court. But it is the shoe that everyone has been waiting to drop. And now it
appears that it will.
Not getting The Dark Report in your mailbox every 3 weeks?
Palmetto Execs Explain
Molecular Test Policies
Goal is to create a process to assess science
and clinical value for molecular tests and LDTs
CEO SUMMARY: To create more transparency in the
process clinical labs use to submit claims for genetic tests,
molecular diagnostic tests, and for laboratory-developed tests
LDT), the nation’s largest Medicare Administrative Contractor
MAC) has proposed two new local coverage determinations
LCD). CMS has changed Palmetto GBA's statement of work to
include implementing a lab test registry and science review
process for genetic,molecular, and laboratory-developed tests.
Palmetto GBA Announces
Molecular Test Registry
Laboratories in California, Hawaii, and Nevada
need to seek approval for each code-stacked test
CEO SUMMARY: Palmetto GBA, the nation's largest
Medicare Administrative Contractor (MAC), is asking labs in
the J1 jurisdiction to submit applications for each molecular
test they run. Molecular assays will receive a unique five-digit
alpha-numeric identifier (Z-code) that will be entered into the
narrative/comment field on claims. A panel of subject matter
experts will evaluate the analytical and clinical validity of the
assays, and to determine the clinical utility of the assay.
Rite Aid Offers Free Tests
To Preferred Customers
National chain has pharmacists discuss
lab test results with rewards program members
CEO SUMMARY: National pharmacy chain Rite Aid now offers
free clinical laboratory tests to members of its customer-rewards
program once they reach certain spending levels. After the customer's
specimen is tested, the laboratory test results are sent
directly to the customer’s local Rite Aid pharmacist. Next, the
pharmacist will discuss the lab test results with the consumer.
This marketing program is the latest example of how pharmacies
want to use lab testing as a way to generate more prescriptions.
Book Review: New Lab Management Resource
For Pathologists, Lab Leaders
"Laboratory Administration for Pathologists"
offers comprehensive and up-to-date information
Anatomic Path Insourcing
Expected to Be Ongoing
Pathologists and lab executives surveyed
affirm their belief that this trend will continue
CEO SUMMARY: Insourcing of anatomic pathology services
by office-based physicians has been especially prevalent and is
increasing among three specialties (gastroenterology, urology,
and dermatology), according to a survey conducted last month.
Survey respondents also indicated that the trend toward
increased insourcing is so strong that it could spread to other
specialty groups such as ob-gyns and oncologists. THE DARK
REPORT and Blair & Company conducted the survey in October.
INTELLIGENCE: Late & Latent
MORE ON: Telemedicine
TRANSITIONS: On December 1, Joseph
Skrisson will become the Chief
Operating Officer at Dynacare
Laboratories, Inc.
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