Genetic Engine Assist Program
Genetic Program
In an era where genomic medicine is rapidly advancing, we recognize the paramount importance of integrating genetic information into healthcare services. Phytest is designed to revolutionize the billing process by leveraging genetic reimbursement data to tailor medical billing and maximize insurance coverage more accurately than ever before.
Our program represents a collaborative effort between healthcare providers, insurers, geneticists, and technology experts. Through rigorous testing and refinement, we are committed to establishing a robust framework that balances the complexities of genetic data with the practicalities of billing and reimbursement.
Patient Cases
Success by Payer
Patient with Aetna Insurance presented with order for Female Carrier Screen.
Test: Beacon ACMG 3 Female Carrier
CPT: 81443
Diagnosis: Z31.440 – Encounter of male for testing for genetic disease carrier status for procreative management
Actions:
Insurance Verification: Verified
Prior Auth: Not Required
Diagnosis: Invalid for Female Patient – Updated Diagnosis to Z31.430 – Encounter of female for testing for genetic disease carrier status for procreative management
Medical Records Review: Not supportive of 81443. Remove 81443.Update CPTs to include codes in panel that follow payer policy for medical necessity. 81220 – CF, 81243 – FX, 81329 – SMA.
Claim Filed On: 02/01/2024
Claim #: 60
Claim Remitted On: 02/15/2024
Billed Amount: $1,350
Contractual Adjustments: $361.58
Aetna Payment: $889.58
Patient Responsibility: $98.84
Patient with BCBS of IL insurance presented with order for Female Carrier Screen.
Test: Beacon ACMG 3 Female Carrier
CPT: 81443
Diagnosis: Z31.430 – Encounter of female for testing for genetic disease carrier status for procreative management
Actions:
Insurance Verification: Verified
Prior Auth: Not Required
Diagnosis: Valid
Medical Records Review: Not supportive of 81443. Remove 81443.Update CPTs to include codes in panel that follow payer policy for medical necessity. 81220 – CF, 81243 – FX, 81329 – SMA.
Claim Filed On: 02/02/2024
Claim #: 90
Claim Remitted On: 02/12/2024
Billed Amount: $1,350
Contractual Adjustments: $817.83
BCBS Payment: $532.17
Patient Responsibility: $0
Patient with Cigna insurance presented with order for Female Carrier Screen.
Test: Beacon ACMG 3 Female Carrier
CPT: 81443
Diagnosis: Z31.430 – Encounter of female for testing for genetic disease carrier status for procreative management
Actions:
Insurance Verification: Verified
Prior Auth: Not Required
Diagnosis: Valid
Medical Records Review: Not supportive of 81443. Remove 81443.Update CPTs to include codes in panel that follow payer policy for medical necessity. 81220 – CF, 81243 – FX, 81329 – SMA.
Claim Filed On: 02/01/2024
Claim #: 20
Claim Remitted On: 02/22/2024
Billed Amount: $1,350
Contractual Adjustments: $994.93
Cigna Payment: $355.07
Patient Responsibility: $0
Challenges
Coding Updates and Changes
Genetic codes are subject to frequent updates and changes, reflecting advancements in technology and understanding of genetics. Keeping up with these changes can be challenging for healthcare providers and billing departments.
Insurance Coverage Variability
Insurance coverage for genetic testing can vary widely depending on factors such as the type of test, the patient's diagnosis, and the insurer's policies. Determining coverage eligibility and navigating pre-authorization requirements can be time-consuming and complex.
Continuing Provider Education
Physician education is essential for accurate billing for genetic testing, compliance with regulations, ethical decision-making, effective patient communication, and the delivery of high-quality care. By investing in physician education, healthcare organizations can optimize reimbursement, mitigate compliance risks, and enhance patient satisfaction and outcomes.
Patient Participation
Patient participation can serve as a form of advocacy and negotiation in the billing process. Patients can communicate with healthcare providers and insurers to advocate for coverage of necessary genetic tests and negotiate billing arrangements to minimize out-of-pocket costs.
Complexity of Coding
Genetic testing involves a wide array of tests, each with its own set of codes for billing purposes. These codes can be intricate and specialized, requiring a knowledgeable billing partner to ensure accurate coding and billing.
Medical Charting
Many insurance providers require documentation of medical necessity to approve coverage for genetic testing. By documenting the reasons for testing in the patient's chart, healthcare providers can support insurance claims and facilitate timely approval for testing, minimizing financial burden on the patient.