Health Plans | Utilization Management Laboratory Management

Medical policy is the foundation for all of eviCore’s solutions, but perhaps even more so for the Laboratory Management solution. eviCore created proprietary evidence-based clinical guidelines built on independent technology assessments, nationally recognized professional guidelines, and peer-reviewed criteria. Our policy library is the most comprehensive in the market, with policies covering more than 500 molecular and genomic tests.

The eviCore Laboratory Management Team applies a surveillance process that continually searches applicable genetic and molecular industry literature for new tests and applicable evidence. We review and update clinical guidelines when new evidence-based literature is published or a new lab test is developed that would result in material change to one of our clinical pathways. All policies are reviewed at least annually, and updates are typically provided twice a year. eviCore’s Laboratory Management clients typically adopt the majority of eviCore’s Laboratory Management policies, but client-specific customizations are possible at implementation. The client-approved molecular and genetic clinical guidelines will be available for ordering providers on our clients’ Web portal once the Laboratory Management solution has been implemented.

Approximately 30% of all genetic tests are not medically necessary or are ordered incorrectly. In addition, eviCore often sees 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 the patients are receiving the right test. To help combat these challenges, eviCore recommends prior authorization for approximately 200 CPT codes that represent tests that are high-cost and highly misused.

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.

eviCore has an optional lab network as part of its Lab Management solution. Our lab network is a national network of molecular and genetic testing laboratories designed to provide a good representation of labs that perform molecular and genomic testing such as testing for hereditary cancers and rare disorders, proprietary/single-source tests with positive coverage policies, and reproductive tests (e.g., NIPT, carrier screening). We have also developed a methodology to effectively manage reimbursement for Unlisted Molecular Pathology Code CPT code 81479. The health plan typically maintains its reference lab network for more commonly ordered tests such as CBCs and other routine lab work and then delegates molecular and genetic testing to eviCore.

eviCore has utilized its expertise to negotiate and maintain its free-standing network at often discounted fees based on knowledge of the required effort to perform the test, in addition to simple market-based pricing, creating an even greater benefit for clients. The participating network labs were handpicked by eviCore’s 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 leaders and single-source labs that fill a specific niche in the molecular and genetic testing space.

eviCore’s genetic experts review hundreds of genetic test requests every day. Many of those requests do meet medical necessity standards. However, a portion of those that do not meet criteria for the requested test meet criteria for another test. In those instances, our expert clinical staff will deny the initial request, but suggest a different test based on the provided clinical history. Working with us, health plans sometimes can expand their benefit coverage for genetic testing because we can help ensure that their members receive the most appropriate genetic testing, while minimizing excess spend for the health plan.

Many of the test requests we review involve tests that show limited or no evidence that the test has been validated or has been proven to change a patient’s treatment. Those tests are often referred to as Investigational and Experimental (I&E). Test results from I&E tests can be misleading and can cause undue anxiety for members. By helping to ensure that members do not have access to those unsupported tests, we help to reduce patient anxiety as well as associated costs.

eviCore’s proprietary integrated system, Claims Studio, ensures that our health plan clients are only paying appropriate claims. For procedure codes that require prior authorization, Claims Studio allows seamless, intelligent coordination of the prior authorization 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 eviCore’s prior authorization program and instead focus on high-volume, low-cost CPT codes. It is important to note that Claims Studio goes beyond the off-the-shelf 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 the Claims Studio savings for the Laboratory Management solution comes from proprietary claim rules designed to enforce clinical policies through fully automated processes, and these rules are not found in the typical claims editing software.