As genetic testing is becoming more and more popular, genetic laboratories are starting to face added problems. Genetic laboratories are the greatest at risk for revenue loss when compared to other laboratories such as Molecular, Toxicology and Infectious Disease laboratories. At Acrev Solutions we understand the challenges genetic laboratories face and that’s why our team is well equipped to tackle any problems now and in the future. Furthermore, Acrev Solutions is knowledgeable about the genetic laboratory billing industry and that is why we establish safeguards to minimize your risk of revenue loss.
Which Tests are More at Risk?
Genetic laboratories that bill MACs (Novitas and FCSO) and are only or largely performing genetic tests like CGX, CARDIO, PGX, etc., are at greater risk. Since these tests are more vulnerable you should soon explore the possibility of offering other tests before it’s too late to maintain financial integrity. While other MAC contractors are resistant in reimbursing the bonanza CPT 81408 that gets paid $2000, some MACs have chosen not to establish appropriate coverage guidelines. The consequence of this has led to CMS paying more than $400 million in 2018 and 2019 on a single CPT code. This is an astonishing statistic because it is more than 400% from 2017 as per the CMS released payment data.
What is CPT code 81408 and Why has it Gained Friction?
CPT code 81408 is a molecular pathology procedure analyzing 50+ exons in a single strand of DNA. As the rare gene CPT code 81408 gets traction from several industry experts, it is likely that federal contractors Novitas and FCSO will soon notice this increase and relate the overpayment with Fraudulent use. If down the line it is labeled as Fraudulent use this can impact genetic labs that are genuine if coverage criteria are amended. Several commercial insurances like UHC have already decided not to pay for this code. Hence it is very important for genetic labs to work on expanding the types of tests offered and not solely rely on genetic testing. Other CPT codes that have gained traction and criticism are 81162 and 81479 (under MolDx states).
Operation Double Helix
After the Department of Justice published $6 billion overpayment fraud under Operation Double Helix it is likely that soon genetic testing will undergo scrutiny. Several pop-up laboratories and reference laboratories will be uncovered for billing genetic tests that are not medically necessary.
If you are a genetic laboratory and want to perform clinical documentation compliance or explore new tests to mitigate risks, feel free to consult us and enhance your billing compliance! You need a billing partner that not only offers premium billing and RCM services but also insight to stay compliant within the laboratory continuum. At Acrev Solutions we can offer you just that and much more.