ST. PETERSBURG, Fla.--(BUSINESS WIRE)--InformedDNA®, the nation's largest independent provider of genetics services, today released details of its Coverage Decision Framework™ which enables health plans to offer members improved access to emerging genetic tests. This innovative approach is described in the latest issue of the company’s original research and analysis series, Informed Insights™, which explores trends and strategies to address barriers as advances in genomics continue to reshape the future of healthcare.
The traditional model for developing medical policy has existed for many years—the backbone of this process is evaluation of evidence that a particular service is beneficial and not likely to be harmful, and under which clinical scenarios. However, evidence-based coverage frameworks used for common conditions are not easily applied to rare genetic conditions and newly developed diagnostics. Rapid advances in genomic science and implementation of personalized medicine require new approaches to health plan policy and genetic test evidence review processes.
“Using incomplete and/or outdated approaches to medical policy for complex tests may place health plans at risk of lagging behind emerging science and being unable to efficiently apply policy to ensure appropriate utilization of the newest genetic tests,” said David Nixon, chief executive officer for InformedDNA. “With the Coverage Decision Framework, our genetics experts have created a forward-thinking approach that assesses the risks and benefits of new genetic tests and enables health plans to efficiently develop timely policies that address new, effective and safe approaches to genomic medicine.”
The framework was designed based on thorough analyses of gaps in existing methods of evidence review. It addresses these gaps by incorporating all relevant factors (drivers) for the evaluation of new genetic tests, thus enhancing transparency and efficiency. The assessment includes details regarding the test platform and validation data, as well as comparison with alternatives and current standards of care.
Study finds direct correlation between prior authorization approvals and genetics expert intervention.
Also published in the company’s Informed Insights series are the results of a study conducted by InformedDNA of 3,828 complex genetic testing prior authorization* requests by U.S.-based health plan clients throughout 2018. Analysis of the submitted requests determined that more than half needed further detail for decision-making. When outreach was conducted to the ordering providers of these requests, 70 percent had clinical discussions with genetics experts to exchange relevant information. Based on provider outreach, InformedDNA found:
- Redirection of the original request to a more medically appropriate test was recommended in 27 percent of cases. These modifications occurred when the original request would have been denied based on the initial documentation submitted.
- Approximately 4 percent of requests resulted in withdrawal of the request. Because these requests were likely to result in a denial and possibly subsequent appeals, withdrawals reduced the administrative burden for both providers and plans.
- 97 percent of providers surveyed reported satisfaction with the prior authorization process.
About this study, Nixon commented, “Advancements in genetic testing are complex and continuous. And, navigation of payer policies and interpretation of test results is challenging due to limited genetics expertise in the market. These results show that without a genetic expert’s intervention, prior authorization denials of genetic test requests will continue to be an issue. However, for plans that have a genetics expert outreach strategy, nearly one-third of genetic test orders can be modified and approved faster. This, in turn, improves provider satisfaction and patient care timelines, as well as eliminating inappropriate tests and costs.”
Informed Insights reports feature original research and analysis from InformedDNA’s genetics experts. For more information, visit https://www.InformedDNA.com/Informed-Insights.
InformedDNA is the authority on the appropriate use of genetic testing. It leverages the expertise of the largest full-time staff of independent, board-certified genetics specialists in the U.S. to help ensure health plans, hospitals, employers, clinicians and patients all have access to the highest quality genetic services. Key offerings include clinical genetic counseling, genetic testing utilization management, genetic testing payment integrity, and expert genetics clinical trial support. For more information: www.InformedDNA.com
*Prior authorization data analyzed in this study is derived from work performed in conjunction with AIM Specialty Health®. Together, the companies provide fully delegated Genetic Benefits Management™ services.