Keep pace with the complexities of genetic testing   

Management across the universe of genetic testing   

Although genetic testing accounts for only about 1% to 2% of medical spend, health plans often dedicate a disproportionate amount of time — as much as 15% of clinical reviews and 20% of medical policies — to managing it. Errors and overpayments occur frequently, and waste is common.  

Due to the volume of orderable tests available, coding variability and increasingly complex medical policies, the effort required to manage genetic testing can seem endless. However, with Evolent’s innovative genetic testing solution, powered by Concert Genetics, we conquer the complexities and deliver end-to-end value.

Key components of our solution include: 

Review of tests, not CPTs 

Traditional genetic testing management solutions focus on authorization of CPT codes, with multiple codes typically submitted for a single test. This results in variability and provider abrasion. Evolent’s program, on the other hand, reviews services at the individual test level.    

• Align authorizations to specific tests being requested — something often not possible with CPT codes, each of which may represent multiple tests.  
• Unify efforts across guideline review, claims/payment integrity and provider network contracting in a tightly integrated manner for all genetic and molecular testing

Technology

Using proprietary technology, all genetic and molecular tests are automatically and continuously monitored and reviewed against medical guidelines, price benchmarks and correct codes.

• Identify relevant medical policies by mapping machine-readable policies to categories and domains of testing
• Apply payment integrity and clinical claim edits to low-cost, high-volume tests

Robust clinical intake algorithms   

Our advanced system enables auto-approval for requests that meet medical necessity criteria.  

• Speed processes and lower costs
• Reduce administrative burden and provider abrasion 

Expert-led peer-to-peer review 

Board-certified clinical geneticists and specialty-matched physicians trained extensively in genetic and molecular testing services review pended cases to ensure medical necessity and clinical appropriateness.

• Maximize program value through medical necessity reviews for high-cost tests with high potential for misuse
• Eliminate medical necessity reviews for tests with little potential for misuse 

With genetic testing growing at an estimated 13% annually and spending projected to reach $10.3 billion by 2027, the unique challenges of this field will continue.