Clinical OMICS

JAN-FEB 2019

Healthcare magazine for research scientists, labs, pathologists, hospitals, cancer centers, physicians and biopharma companies providing news articles, expert interviews and videos about molecular diagnostics in precision medicine

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www.clinicalomics.com January/February 2019 Clinical OMICs 35 recommendation states that when a patient has a definitive pathogenic variant, his or her relatives should get genetic testing. But if the patient is not allowed to get tested, there is no way of knowing if a variant is present, or of protecting the family. A reasonable person would assume that anyone who met the ACC guidelines would be able to get the test. This patient met the guideline's requirements. My col- league spent 65 minutes on the phone getting bounced between employees at the benefits management company and the private payer who were polite and completely unhelpful. She got a denial. Why? Although she had every required patient identifier, the payer had an old address in its files that didn't match the patient's current address, and the address change could only be made by the patient. My colleague tracked down the patient, initiated a three- way call with the company and got it done. In a third call to the benefits management company, she finally reached a cli- nician—a genetic counselor—who explained that the payer would deny the claim. How the denial was phrased tells the story: the payer 's commercial policy is very restrictive and doesn't align with best practice standards. The insurer 's policy has nothing to do with what phy- sician experts determined is necessary for patient care. the payer made up a clinical pathway that allows it to with- hold payment. There was no concern about the patient and the poten- tially lethal outcome for the patient's family members, not to mention that now every person in the patient's immedi- ate family needs to be screened with echocardiogram, elec- trocardiogram and potentially other tests on a regular basis, further driving up medical costs. This is one incident with one patient; genetic counselors and physicians across the country are getting this response every day for nearly every insured patient of this insurer who needs genetic testing for any disease, including cancer, which I have personally expe- rienced on more than one occasion. This is an irresponsible way to conduct business for people who need the tests. I do not understand why this insurer, and other insurance companies following their lead, even require prior authorization for tests that comply with national guidelines and are, by definition, medically neces- sary. This is why we send our consult notes, family trees, and supply endless ICD-10 codes to the insurers to begin with. How long will labs be able to maintain genetic testing services when they cannot get paid, leaving genetic counsel- ors like me without a source of obtaining critical data. I am a genetic counselor who cares for and about patients. That is my job. Federal and state government policy makers have the job of protecting patients from insurance company policies that are harmful. They need to address private pay- ers' misuse of prior authorization through legislation or reg- ulation, and make sure patients get life-saving tests. Scott M. Weissman, Certified Genetic Counselor "Prior authorization has been around for a long time. These policies require providers, such as doctors or laboratories, to get permission from an insurance company before providing a service like genetic testing." wutwhanfot / iStock / Getty Images

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