An Integrated Approach to Genetic Test Stewardship: The Role of Laboratory Genetic Counselors in Test Preauthorization and Ordering

Abstract

Abstract Introduction The complexity and relative high cost of genetic tests combined with stringent administrative and medical coverage policies can negatively impact test accessibility and, ultimately, patient care. The burden of test preauthorization typically falls on the ordering provider and team, and is particularly cumbersome for specialists that do not have genetics expertise. As part of the Seattle Children’s laboratory stewardship program, we integrated laboratory genetic counselors (GCs) in a hospital-wide genetic test preauthorization and order review process to support efficient test authorization and ensure appropriate genetic test utilization. Methods A rotating team of laboratory GCs reviews all genetic test requests at the time of preauthorization for medical necessity, optimal test selection, and CPT coding. This information is triaged to our centralized insurance processing department for submission to payers. Lab GCs review test orders for the same elements, preauthorization status, and supporting paperwork. Conclusions The 7,889 preauth requests and 7,177 test orders have been reviewed in our institution since implementing this two-phase review process in January 2016. Twenty-eight percent of requests were modified or cancelled at the time of preauth review, with the majority of modifications related to test optimization and improved necessity documentation. Additionally, 21% of requests were modified or cancelled when reviewed at the time of order. The intervention resulted in $1.5M cost-avoidance accrued since 2016. A recent provider survey revealed that 90% of providers are neutral, very, or extremely satisfied with the genetic test authorization process and support provided by the laboratory GC team. By integrating a laboratory GC case review process, we supported effective genetic test utilization at our institution, reduced collective provider and staff time and rework related to insurance authorization, and reduced financial liability for the patient/family and institution.