Genetics and managed care: Policy statement of the American College of Medical Genetics

Genetic testing insurance coverage trends: a review of publicly available policies from the largest US payers

AIM

Health plan coverage policies can influence utilization of genetic tests. Our goal was to characterize the current state of test-related policies from US private payers.

METHODS

We searched the public websites of 206 insurers for coverage policies. We documented the number of policies, tests mentioned, coverage determination and policy effective dates.

RESULTS

Approximately one-third of insurers had at least one genetic testing policy. Moderate consistency was seen between payers. Tests in oncology and personalized medicine were most frequently addressed. Half of the policies specifically excluded coverage of a particular genetic service. Nearly half of insurers had at least one out-of-date policy.

CONCLUSION

Genetic services are addressed by many large health plans. Challenges remain in ensuring consistency and currency of payer policy for genetic tests.

A large health system's approach to utilization of the genetic counselor CPT® 96040 code

PURPOSE

: In 2007, CPT® code 96040 was approved for genetic counseling services provided by nonphysician providers. Because of professional recognition and licensure limitations, experiences in direct billing by genetic counselors for these services are limited. A minority of genetics clinics report using this code because of limitations, including perceived denial of the code and confusion regarding compliant use of this code. We present results of our approach to 96040 billing for genetic counseling services under a supervising physicians National Provider ID number in a strategy for integration of genetics services within nongenetics specialty departments of a large academic medical center.

METHODS

: The 96040 billing encounters were tracked for a 14-month period and analyzed for reimbursement by private payers. Association of denial by diagnosis code or specialty of genetics service was statistically analyzed. Descriptive data regarding appointment availability are also summarized.

RESULTS

: Of 350 encounters January 2008 to February 2009, 289 (82%) were billed to private payers. Of these, 62.6% received some level of reimbursement. No association was seen for denial when analyzed by the diagnosis code or by genetics focus. Through this model, genetics appointment availability minimally doubled.

CONCLUSION

: Using 96040 allowed for expanding access to genetics services, increased appointment availability, and was successful in obtaining reimbursement for more than half of encounters billed.

Health insurance coverage of genetic services in Illinois

PURPOSE

As a first step toward the improvement of health insurance coverage and reimbursement for genetic services, our study characterizes the current state of health insurance coverage for genetic services in Illinois.

METHODS

We used a combination of surveys, interviews, and policy review to obtain data from the largest health insurers in Illinois regarding their coverage of genetic services.

RESULTS

The health insurance companies in this study vary widely on coverage of and attitudes toward genetic services. Policies were most consistent across insurance companies when there was widespread professional agreement regarding genetic testing, as in the case of cystic fibrosis carrier screening. Other policies, including criteria for BRCA testing, were extremely variable across insurers and did not always reflect accurate medical information. We also found that health insurance companies in Illinois seem unlikely to reimburse for services billed directly by genetic counselors.

CONCLUSIONS

These findings suggest several strategies for improving billing, reimbursement, and insurance coverage of genetic services, including (1) legislative amendments mandating coverage of genetic counselors' services; (2) creating consistent criteria for genetic testing; (3) increasing genetic professionals' involvement in the development of coverage policies; and (4) educating insurance companies about the value of genetic services.

Exploring the public understanding of basic genetic concepts

It is predicted that the rapid acquisition of new genetic knowledge and related applications during the next decade will have significant implications for virtually all members of society. Currently, most people get exposed to information about genes and genetics only through stories publicized in the media. We sought to understand how individuals in the general population used and understood the concepts of "genetics" and "genes." During in-depth one-on-one telephone interviews with adults in the United States, we asked questions exploring their basic understanding of these terms, as well as their belief as to the location of genes in the human body. A wide range of responses was received. Despite conversational familiarity with genetic terminology, many noted frustration or were hesitant when trying to answer these questions. In addition, some responses reflected a lack of understanding about basic genetic science that may have significant implications for broader public education measures in genetic literacy, genetic counseling, public health practices, and even routine health care.

Faculty Members Perceptions of Medical Genetics and Its Integration into Nurse Practitioner Curricula

This study assessed faculty members' perceived knowledge of medical genetics concepts and conditions, the importance of integrating this content into NP curricula and how this was being done. During a national NP conference, 40 NP faculty voluntarily completed surveys. Participants' perceived knowledge of genetics varied; 35% noted low or very low knowledge, and only 5% reported high or very high knowledge. Most participants (95%) believed genetics is important, but only 10% reported having separate genetics courses in their NP programs. Approximately half of the participants reported personal involvement in genetics NP education, and 50% reported barriers to implementing it into their curricula. Most faculty indicated they did not feel comfortable teaching genetics, nor did they have formal training in the area. Advancing medical genetics into NP curricula will require ongoing faculty development and training to sustain and build genetics skills and competencies for advanced practice nurses.

The impact of genetic information on policy and clinical practice

This article discusses genetics-related policy issues that have an impact on health care systems, health care providers, and their patients: privacy, mass screening, family screening, and knowledge dissemination. Access, cost, and ethical implications are important discussant points for each of these genetic-related policy issues. Embedded in the issue of privacy are concerns of insurability, confidentiality, and discrimination. The public health policy implications related to mass screening programs include efficacy of the screening tests, availability of primary and secondary interventions, access, costs, and program evaluation. Policy issues for family screening are similar to mass screening, with added concerns about privacy and availability of adequate resources, including health care providers and counselors trained in genetics. Knowledge dissemination is critical to maintaining currency of clinical information and applications of genetic technologies and treatments. As genetic information expands, the need for knowledge dissemination will increase. The importance of advanced practice nurses' involvement in these policy issues is discussed.

Fetal magnetic resonance imaging and human genetics

The use of fetal magnetic resonance imaging (MRI), in addition to prenatal genetic testing and sonography, has the potential to improve prenatal diagnosis of genetic disorders. MRI plays an important role in the evaluation of fetal abnormalities and malformations. Fetal MRI often enables a differential diagnosis, a determination of the extent of the disorder, the prognosis, and an improvement in therapeutic management. For counseling of parents, as well as to basically understand how genetic aberrations affect fetal development, it is of great importance to correlate different genotypes with fetal MRI data.

Barriers to the provision of genetic services by primary care physicians: a systematic review of the literature

PURPOSE

The purpose of this literature review is to report primary care physicians' perceived barriers concerning the provision of genetic services.

METHODS

Sixty-eight papers were identified in six electronic databases. Only publications classified as empirical studies (N = 18) were included in this review.

RESULTS

Barriers identified most frequently in reviewed studies were inadequate knowledge of basic genetics, lack of detailed or updated family histories, lack of confidence, and lack of referral guidelines.

CONCLUSION

Although many primary care physicians perceive genetics as a low practice priority, they do report a need for educational programs in genetics, informational resources, and referral guidelines.