The impacts of genomics and affordability
While lab-developed tests offer valuable insights, ensuring test quality remains crucial for reliable results and comprehensive health plan coverage is paramount. Evolving state-level biomarker mandates encourage insurers to cover comprehensive testing, but policy gaps persist, and patients may face cost hurdles. It can be a specialized and costly process.
Integrate our cutting-edge science to better manage your genomic and routine laboratory reimbursement.
Accurate payments and testing management
Genomics Payment Manager
Optum Genomics Payment Manager, available exclusively through a license with Palmetto GBA and the DEX Diagnostics Exchange Registry, facilitates alignment among health plans, providers and labs. It ensures accurate claim submission and reimbursement by providing essential information for genetic testing claims.
This innovative solution addresses the challenges posed by rapid growth in this field, surpassing traditional policy and coding structures.
Laboratory benefits management
Optum collaborates with Avalon Healthcare Solutions to provide comprehensive laboratory benefits management.
Routine testing management
Routine Testing Management focuses on controlling utilization through policy management and automated adherence. Up to 30% of lab tests may be unnecessary, and there’s a 2x-3x cost variation across different sites.
Precision genetic testing management
Precision Genetic Testing Management focuses on genetic test utilization through policies, prior authorization services, and unique genetic test identification.
Key benefits
Our comprehensive approach optimizes quality while reducing spend.
Test identification and quality
We have an exclusive partnership with Palmetto GBA, the administrator of DEX® Z-Codes and the DEX test registry.
Network solutions
Realize cost savings with pricing solutions at the individual test level.
Decision support
Medical and reimbursement criteria for a broad range of laboratory testing to help drive automation and clarity.
Claims management
Our solutions contain automated enforcement of policies leveraging DEX Z-codes and proprietary authorization to claim matching rules.
Manage laboratory spend and utilization
- Limited federal oversight, until recently, with no single identifier or framework for evaluating test quality
- 175K+ clinical genetic tests1
- 500+ CPT® codes available2
- Need for greater transparency and alignment
- $2B+ of fraud identified by U.S. Department of Justice annually for code stacking3
Complementary solutions
DME Navigator
Ancillary Benefits Management
Related healthcare insights
On-demand webinar
Optum and Palmetto experts partner in discussing how to solve genetic lab challenges in legacy solutions.
On-demand webinar
Understanding the challenges confronting Medicare Advantage plans and their Medical Loss Ratio.
White paper
Learn two critical indicators causing these denials, and how to account for them effectively.
- Halbisen AL, Lu CY. Trends in Availability of Genetic Tests in the United States, 2012-2022. J Pers Med. April 6, 2023; 13(4):638.
- Laboratory Hub. Understanding CPT and ICD Codes in Laboratory Billing. Accessed June 28, 2024.
- U.S. Department of Health and Human Services Office of Inspector General. Nationwide Genetic Testing Fraud. Accessed June 28, 2024.