Originally Published IVD Technology May 2005
INDUSTRY NEWS
HHS committee explores genetic test reimbursement
Richard Park
At a recent meeting, the Secretary’s Advisory Committee on Genetics, Health, and Society (SACGHS) discussed the current problems in the coverage and reimbursement of genetic tests and services that are adversely affecting the integration of genetic technologies into the healthcare system. The committee has drafted a report that includes proposed recommendations for addressing the barriers to reimbursement of genetic tests.
“The ultimate goal of course is to improve access to and utilization of genetic tests and services by ensuring appropriate coverage and reimbursement,” said committee member Cynthia E. Berry, a partner at Powell Goldstein Frazer & Murphy (Washington, DC).
One of the barriers the committee examined was Medicare’s influence on private health insurance plans and the fact that Medicare is often the model used for determining coverage of benefits. The report pointed out that since genetic technologies may not be widely used or appropriate for more-senior populations, Medicare is probably not the best model for private plans that cover other nonsenior populations.
“This recommendation encourages private health plans to make their own coverage determination about genetic tests and services rather than using Medicare as a model,” said Berry.
Another barrier the committee looked at was the differences among local Medicare coverage determina- tions for genetic tests, and the decision-making processes involved for such coverage. In order to avoid any inconsistencies in local coverage, the committee recommended the adoption of a national coverage determination for genetic tests.
“We encourage the Centers for Medicare and Medicaid Services (CMS; Baltimore) to move forward with the implementation of a provision in the Medicare prescription drug act, which requires a plan to be developed to evaluate new local coverage decisions and determine which should be adopted nationally,” said Berry.
The committee also discussed Medicare’s screening exclusion. The Medicare statute states that coverage is not provided for screening tests and services for risk assessment purposes. Nevertheless, the committee believes that such preventive services, including predispositional genetic tests, should be covered by Medicare. However, the committee realized that coverage for such tests would require a change in the statute, or a Congressional action to add a benefit category for preventive services.
“Absent that, the fallback would be that CMS would issue a national coverage decision stating that family history constitutes a medical justification for genetic tests being reasonable and necessary,” said Berry.
Medicaid is another issue the committee examined. Each state has its own Medicaid program with its own benefits, and has budget requirements that create some instability in terms of coverage for all services, especially for genetic tests. The committee recommended that the Secretary of Health and Human Services should provide the states with the appropriate information and guidance to help them make coverage decisions and determine how to structure their Medicaid programs.
Regarding billing and reimbursement, the committee looked at the current procedural terminology (CPT) modifier codes for genetic tests and services. The committee recommended that health providers and health insurance plans should work together to reach a consensus on this matter. The committee suggested that a private sector group should assess the impact of the CPT modifier codes on claims denial rates. The committee specifically identified the Genetic Test Coding Work Group as an entity that was involved in developing the modifier codes and might be an appropriate group to perform these tasks.
The committee also expressed its concerns regarding the discrepancy between the costs of providing genetic tests and the Medicare reimbursement rates for these tests. Considering that the fees being paid by Medicare are inadequate, the committee encouraged CMS to use its inherent reasonableness authority to address these variations in payment rates. Berry added that this barrier is especially poignant considering that “lab fees are frozen until 2009, with no changes to payment rates expected statutorily in the near future,” according to the Medicare clinical laboratory fee schedule.
Additional information about the committee and its report may be accessed via the SACGHS Web site at www4.od.nih.gov/oba/sacghs.htm.
Copyright ©2005 IVD Technology
