Health Plans | Utilization Management

Laboratory Management

Our Laboratory Management solution utilizes both broad and test-specific medical policies to improve the quality of clinical decisions for patients while reducing laboratory costs for genetic, molecular and genomic testing. This solution helps ensure that health plans pay the right amount, on the right claim, for the appropriate test. The core components are medical policy, prior authorization (PA), payment integrity, and lab network.

Medical Policy (Clinical Guidelines)

Medical policy is the foundation for all our solutions and is particularly relevant for the rapidly changing field of Laboratory Medicine. We created proprietary evidence-based clinical guidelines based on independent technology assessments, nationally recognized professional guidelines, and peer-reviewed scientific literature. Our policy library is the most comprehensive in the market, with policies covering 500+ molecular and genomic tests.

Policy Updates

The Laboratory Management Team applies a surveillance process that continually reviews the published, evidence-based molecular and genomic industry literature for any studies or new lab tests that would result in material changes to one of our clinical policies. All policies are reviewed and updated with any pertinent new scientific information at least annually. Health plans typically adopt the overwhelming majority of our policies, but plan-specific customizations are possible during implementation. When a health plan implements our Laboratory Management solution, providers can view the approved molecular and genomic clinical guidelines on the plan’s online portal.

Prior Authorization

Approximately 30% of all genetic tests are not medically necessary or are ordered incorrectly. In addition, we often see genetic test claims in excess of $10,000 for a single patient on a single date of service. Together, these issues support the need for some type of intervention to make sure patients are receiving the right test at the right price. To help combat these challenges, we recommend PA for approximately 200 CPT codes representing tests that are high-cost and highly misused.

Process

Ordering physicians or laboratories can request a prior authorization via the phone or the Web. The user is asked a set of questions based on medical policy, and if the answers meet the criteria, the user immediately receives an authorization. If the case does not immediately meet the criteria, it is sent to an eviCore American Board of Genetic Counseling-certified genetic counselor who may approve the case, or send it to a medical director for further review. Only eviCore’s lab-specific medical directors (board certified in medical genetics, pathology, or oncology) can issue a denial. About half of all eviCore Laboratory Management prior authorizations receive immediate authorization, and the vast majority are concluded within one business day.

Lab Network

Our optional lab network is a national network of molecular and genomic testing laboratories designed to represent available proprietary/single-source tests. That includes tests for hereditary cancers and rare disorders, with positive coverage policies, and reproductive tests (e.g., non-invasive prenatal testing, carrier screening). We have also developed a methodology to effectively manage reimbursement for Unlisted Molecular Pathology Code CPT code 81479 through this network. The health plan typically maintains its reference lab network for more commonly ordered tests such as CBCs and other routine lab work, as well as many genetic tests, and then adds additional molecular and genomic tests through our network.

Network Benefits

We leverage our expertise to negotiate and maintain a freestanding network, often at discounted fees, based on knowledge of the required equipment and effort to perform the test. We use this knowledge to apply simple market-based pricing, creating an even greater benefit for health plans. The participating network labs are handpicked by our lab experts for their quality and the breadth, uniqueness, or relevance of the testing they provide. The lab network is a mix of nationally recognized reference laboratories and single-source labs that fill a specific niche in the molecular and genomic testing space.

Member Benefit

Our genetic experts review hundreds of genetic test requests every day, many of which meet medical necessity standards. Some requests meet criteria for another test instead of the requested one. In those instances, our expert clinical staff does not approve the initial request and suggests a different test based on the provided clinical history. Working with us, health plans sometimes expand their benefit coverage for genetic testing because we help ensure their members receive the most appropriate genetic testing while minimizing excess plan spending.

Investigational and Experimental

Our genetic experts review hundreds of genetic test requests every day, many of which meet medical necessity standards. Some requests meet criteria for another test instead of the requested one. In those instances, our expert clinical staff does not approve the initial request and suggests a different test based on the provided clinical history. Working with us, health plans sometimes expand their benefit coverage for genetic testing because we help ensure their members receive the most appropriate genetic testing while minimizing excess plan spending.

Claims Studio

Our proprietary integrated system, Claims Studio, ensures that health plans are only paying appropriate claims. For procedure codes that require PA, Claims Studio allows seamless, intelligent coordination of the PA results with claim processing. However, the majority of the 44,000+ lab-specific rules within Claims Studio impact CPT codes that are not managed by our PA program and instead focus on high-volume, low-cost CPT codes. Importantly, Claims Studio goes beyond the claims editing software that health plans often already have in place. While Claims Studio does contain the industry-standard claim edits found in that software, approximately 65% of Claims Studio savings for Laboratory Management comes from proprietary claim rules designed to enforce clinical policies through fully automated processes. These rules are not found in the typical claims editing software.

Frequently Asked Questions

How are policies created and updated?

Laboratory Management policies are written internally by expert staff and reviewed by internal and external medical advisory boards. Policies are reviewed at least semi-annually but can be updated more often if significant new evidence is identified. We consider peer-reviewed publications and guidelines from all major professional societies when creating clinical policies. Our Lab Policy book is the most comprehensive in the market, including policies that cover more than 500 genetic tests.

What claims are subject to claims review?

Technically, all claims for CPT codes that are in scope are subject to claims review. We review the claim to make sure it received any necessary PA. In addition, we automatically apply more than 44,000 lab-specific claim rules to ensure appropriate reimbursement for medically necessary tests. The vast majority of these rules apply to low-cost, high-volume tests that are not subject to PA.

How does eviCore handle large gene panels?

Most panels require PA. When panels are billed with individual codes for the genes in a panel, we review the medical necessity of each gene within that panel and typically only approves reimbursement for those genes that are medically necessary. In addition, many panels now have a panel-specific CPT code, but some labs are still billing with multiple stacked CPT codes. We will re-direct those panels billed with multiple codes to the appropriate single-CPT panel code. That way, we help ensure plans only pay claims that are appropriately coded.

What if I have a question about a prior authorization result?

Both the referring and rendering provider (the laboratory performing the test), if known, will receive a copy of the determination correspondence for each case review. Providers can contact us at the number provided on the case correspondence to discuss a PA decision or schedule a peer-to-peer conversation. We believe physician-patient communications are essential to the delivery of quality care; consequently only providers are allowed the opportunity to discuss case-specific determinations with our medical directors and genetic counselors. We will not discuss a case determination directly with a patient.

How do I request copies of utilization review guidelines?

To request copies of utilization-review criteria, please complete this form and submit the request via email to reqcriteria@evicore.com or fax it to 1-866-699-8160, Attention: Request for Criteria.