Why Lab Tests and Their Values Matter to Health Plans in 2022

Avalon Healthcare Solutions hosted a webinar covering the importance of lab management to health plans in 2022. The webinar content included:

At-Home COVID-19 Testing

One focus was the federal requirement for health plans to cover the cost of over-the-counter, at-home COVID-19 tests authorized by the FDA until the end of the Public Health Emergency. The requirement provides reimbursement for up to eight lab tests per member per month beginning January 15th 2022. Now, members with private insurance can access rapid tests in two ways:

  • By submitting a claim for reimbursement with a receipt
  • Through preferred networks established by insurers

Genetic Lab Testing

Avalon, in this highly complex and evolving environment, is also keeping a pulse on the rise in genetic lab tests. The Office of the Inspector General (OIG) reported that Medicare costs are rising exponentially. In the past few years, “total Medicare payments to laboratories for genetic tests quadrupled.”

While some genetic testing is warranted, the explosion in genetic tests has led to overuse and misuse. But there is good news. In a preliminary analysis, over the past 5 years, Avalon has seen less than 10% in genetic spend increases each year – markedly lower than Medicare.

Analytical Validity of Lab Testing

A few concepts in lab testing should guide us towards the right test.  “There are few absolutes in testing,” Rahul Singal, MD, cautions. In other words, it’s important to be careful, as not every test works as intended. He points to a recent New York Times article on prenatal testing.  The article shows the difference between gold standard tests that have stood the test of time – such as prenatal tests for an extra chromosome –and the newer tests, which target micro-deletions in DNA. Some of the new “rare disorders” tests have false positive rates of up to 80%, meaning they are very wrong, much of the time.

Two definitions guide an understanding of the analytical validity of lab testing:

  • Higher sensitivity tests: limit the number of false negatives
  • Higher specificity tests: limit the number of false positives

When it comes to lab tests, sensitivity and specificity help us assess how accurate a test performs in a given clinical situation.

As 2022 begins, Avalon will continue to help healthcare insurers proactively inform appropriate care, reduce costs, and improve clinical outcomes. Click the link below to access the webinar, download slides, and learn more.

HHS OIG Data Brief (2021, December 21) Trends in Genetic Tests Provided Under Medicare Part B Indicate Areas of Possible Concern https://oig.hhs.gov/oas/reports/region9/92003027.pdf

Register for the September Webinar

Tuesday, September 17
2 – 3 p.m. EDT

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