As part of our continued effort to provide a high quality user experience while also ensuring the integrity of the information of those that we service is protected,
we will be implementing changes to evicore.com in the near future.
Beginning on 3/15/21, web users will be required to log in to evicore.com in order to check the status
of authorization request(s). Please click here to register for an account.
Dr. Lon Castle is eviCore’s Chief Medical Officer for Molecular Genetics and Personalized Medicine. He sat down with us to discuss the rapidly evolving, enormously complex world of laboratory testing and why it is so important for patients to get the right lab test to meet their clinical needs.
There are three main issues eviCore is trying to address. First, there are thousands of lab tests on the market, but many of them provide little value to patients. To give you some perspective, there are over 160,000 genetic tests currently available [1], with one or two new tests launched every day. These tests are often made available before the necessary clinical studies have demonstrated how they impact patient care, so we do not know what value they really provide.
Second, even potentially helpful tests are not always used in ways that align with patients’ clinical needs. For example, almost a third of genetic tests ordered do not meet current evidence-based medical guidelines, meaning they are unlikely to benefit patients [2].
Finally, often lab tests are not billed correctly. Around 700 CPT® codes are used to represent the 160,000+ molecular and genomic tests on the market today. Most lab claims include more than one CPT code when billing for these tests, and many of those CPT codes are not transparent about the exact test being performed. Overbilling occurs frequently and can exceed $10,000 for a single test [3]!
Our Laboratory Management solution ensures patients get lab testing that is aligned with the latest medical science, and ensures clients are only paying appropriate claims, which helps to lower premiums and to reduce out-of-pocket costs for everyone.
Helping patients get evidence-based lab tests is critical because the results typically inform next steps. Lab tests influence an enormous two-thirds of clinical decisions [4], which means getting the wrong test can lead to a cascade of unnecessary additional tests and referrals, leading to potentially incorrect or even harmful patient care.
The human and financial costs for these low-value tests also add up fast. For example, doctors often order targeted genetic testing to help guide their treatment decisions. However, labs are increasingly marketing more expensive panel testing, which tests several genes at once, including genes and conditions that go beyond what the patient’s doctor needs to evaluate. Often, the report of these extensive panel tests will include “variants of unknown significance” on genes that were not originally targeted. This unhelpful result may lead to patient anxiety, incorrect diagnoses, unnecessary costs and further testing that does not impact the patient’s health outcomes.
eviCore wants to focus where it can make the biggest difference, so we use our evidence-based clinical guidelines to determine the appropriateness of a strategic set of highly misused, high-cost tests. Our guidelines are based on information from medical societies like the American College of Medical Genetics and Genomics and the National Comprehensive Cancer Network®, as well as recently published, peer-reviewed medical studies. These guidelines are created and maintained by eviCore specialist physicians and genetic counselors, reviewed by external experts, updated at least annually, and available to anyone on our website.
eviCore also relies on an outstanding clinical team, which includes nearly 500 board-certified physicians. Other experts on our team include genetic counselors and more than 1,200 nurses and additional clinicians with experience across multiple specialties. Only an eviCore physician can make the determination that a request does not meet the evidence-based guidelines. For Laboratory Management, our physicians are board-certified in medical genetics, oncology or pathology.
You can learn more about eviCore’s Laboratory Management solution on our website.
[1] The Genetic Testing Unit (GTU): A unique identifier for every genetic test, accessible royalty-free by all. Concert Genetics. June 2021, v1.0.
[2] Miller C. Using genetic counselors to decrease errors in test ordering. Clin Lab News. 2012. Confirmed by internal data.
[3] eviCore claims experience
[4] Health Affairs, “The Emerging Use By Commercial Payers Of Third-Party Lab Benefit Managers For Genetic Testing,” 23 Oct. 2019. Accessed 25 Jul 2022. https://www.healthaffairs.org/do/10.1377/forefront.20191021.563154/full/