Insurance/Billing - Boards

Prior Authorization

Meaning: Insurer approval BEFORE a test/service is performed (pre-service review process)

• Need to submit

  • Lab, Test name, and test ID code

  • CPT Code

  • ICD10 code

  • Personal and family history

  • Supporting guidelines/medical-necessity information

Purpose: Determine whether proposed testing meets the insurer's requirements before proceeding.

Approved

• Approval DOES NOT MEAN guarantee of payment/coverage

• Could still have to pay for because of:

  • Deductible

  • Coinsurance/copay

  • Out of Network

  • Eligibility issues

  • Difference between authorization and final claim

Denied

• Can submit an APPEAL which may involve

  • Letter-of-Medical Necessity

  • Peer-to-Peer Review: discuss testing with a physician to see if testing is medically necessary

• Proceed with testing, but won’t know if it is covered → Self Pay or Lab Financial assistance

Letter of Medical Necessity

• Patient information — relevant demographics and identifying/insurance information as required.

• Clinical indication — diagnosis, symptoms, cancer history, abnormal findings, etc.

• Relevant family history/pedigree — especially features supporting a hereditary condition.

• Test being requested — specific gene/panel/test and laboratory when relevant.

• Why the test is medically necessary — connect the patient's history to the suspected condition and explain why this testing approach is appropriate.

• Supporting evidence/guidelines — e.g., applicable professional society guidelines, insurer criteria, or literature.

• How results will change management — surveillance, surgery, treatment, reproductive management, testing of relatives, etc.

• Why alternatives are inadequate, when relevant — particularly if the insurer suggests a different/less comprehensive test.

• Provider information/signature and appropriate diagnostic/procedure information as required.

CPT Code

• Represents the specific test or service being done

• 96040 = genetic counseling

ICD Code

• Represents the diagnosis suspected diagnosis and reason for testing

Explanation of Benefit (EOB)

• A letter from the insurance company explain how it process a healthcare claim

  • ***NOT A BILL***: tells the patient what happened after a provider/lab submitted a claim

Shows:

• Amount Billed: what the lab/provider charged

• Allowed amount: the maximum sum a health plan will pay for a covered service

  • the amount the insurance company uses as the basis of what % you would pay → NOT the amount the doctor may have billed them for initially

• Insurance payment: what insurance ACTUALLY paid

• Patient responsibility what the patient needs to pay

  • Deductible

  • Copay

  • Coinsurance

    • (allowed amount X your fixed coinsurance % = what you need to pay)

• Denial/noncovered amount (if applicable)

Premium

• Regular payment to have an active health insurance plan

  • TYPICALLY: Higher premium = lower deductible

  • Taken out of paycheck if employer sponsored Health insurance plan

Deductible

• The amount to pay out-of-pocket for services before health plan starts covering costs

  • Typically an annual amount

• Once it is met you pay either:

  • Coinsurance: a set % of the bill

  • Copay: a flat fee for services

High Deductible Health Plan (HDHP)

• A health plan with a high deductible but:

  • Lower premiums

• Good option for people who are healthy and don expect much medical care

• Typically are eligible for Health Savings Account (HSA)

Health Savings Account

• Money taken out of a paycheck and put into an account

  • Pre-Tax money

  • ONLY for medical expenses

  • only for HDHP

• CANOT BE USED TO COVER THE INSURNACE PREMIUM

Coinsurance

• The % of the bill you pay after your deductible has been reached

  • ****Insurance may not cover 100% of bill even after deductible is met*** (that’s where out-of-pocket maximum comes in)

Copay

• Flat fee for different services

Out-of-Pocket Maximum

• The maximum amount a family will have to pay for COVERD services

  • ANNUAL

  • Insurance pays 100% after this amount is paid by the family

Covered Services

• Insurance will pay all or part of the cost

• Does not mean there will not be a bill → patient may still need to

  • meet deductible

  • pay coinsurance %

  • Pay copay

TriCare Insurance

• Military service insurance plan for active military and their dependents

  • Active duty military

  • Military retirees

  • Depdents of miltiary

  • Certain surivors/former spouses

• ****GINA DOE NOT APPLY TO TRICARE****

Medicaid

Run By: Federal + State (federally funded, state administered)

Primarily for:

• Low income (****INCOME BASED****)

• Eligibility requirements vary by state

  • Children

  • Pregnant

Coverage

• Varies significantly by state

Medicare

Run By: Federal government

Primarily for:

• Age 65 and Older

• Certain disabilities/medical conditions

  • ALS

  • End-Stage Renal Failure/Disease

Coverage

• More uniform,

• Specifics Parts

  • Part A: Hospital (admission) - 80%

    • Inpatient

    • Skilled nursing faciality

    • Hospice

  • Part B: Medical (basic medical) - 80%

    • Outpatient medical services

    • Physician services

    • Diagnostic test

  • Part C: Medicare Advantage (commercial/private)

    • private insurance providing Medicare benefits

  • Part D : Drugs

    • Prescription drug coverage

• DOES NOT COVER

  • Dental, Vision, and Hearing Care + Longterm Care

Medical Necessity

• covers genetic testing when

  • coverage requirements are satisfied

  • testing is medically necessary for diagnosis/treatment

Affected patient + test affects medical management → stronger Medicare coverage rationale

Healthy person + purely predictive testing → potential Medicare coverage problem

Balance Billing

• The bill for the difference between the charge for services/testing and what the health plan paid

  • Medical Bill - Insurance payment = “Balanced Bill” you need to pay

• *****Hospital and Labs that accept Medicare/Medicaid are NOT ALLOWED to balance bill EVEN IF services were not 100% covered*****

Preferred Provider Organization (PPO)

• A health insurance plan that allows patients more flexibility to choose healthcare providers OUTSIDE OF NETWORK

  • Usually a higher out of pocket cost (Service)

  • Usually higher premium (Insurance)

  • More flexibility

  • ***No need for PCP referral to see specialist***

• Greater out of Network flexibly DOES NOT MEAN everything/ever lab will be covered

Health Matience Organization (HMO)

• Health insurance plan where you need to use a defined network of providers

  • Require a Primary Care Provider (PCP)

  • Can only see In-Network providers

  • PCP referral needed for specialists (lie Genetic Counselors)

  • More coordinated

  • Lower monthly premiums than PPO

• ****Important: MAY NOT COVER EMERGENY OUT-OF-NETWORK MEDICAL CARE****

Genetic Information Non-Discrimination Act (GINA)

• Federal law that prohibits discrimination based on genetic information for:

  • Health insurance: cannot deny or alter coverage, increase premiums, require/request testing

  • Employment: cannot use info to hire, fire, change employment

• What is genetic information

  • Individuals genetic test results

  • Family members genetic test results

  • ***FAMILY MEDICLA HISTORY** (like fam hx of cancer)

What GINA does not cover:

• Special insurances

  • Life insurance

  • Disability insurance

  • Long-term care insurance

• Military

• People on Indian Health Service (for native Americans)

• Companies with fewer than 15 employees

The Affordable Care Act (ACA)

• Pre-Existing conditions: insurance companies cannot deny coverage or charge higher premiums for people with pre-existing conditions

• People can stay on parent’s insurance plans until 26yo

Consolidated Omnibus Budget Reconciliation Act (COBRA)

• Requires group health plans to continue to TEMPORAILTY cover a person after losing their coverage

  • Usually after losing their job

  • Divorce

  • Dependent child losing dependent status

  • Up to 18months

Former employee → generally pays the entire premium + potentially a small administrative fee

Health Insurance Portability and Accountability Act (HIPPA)

Protects health information (PHI) privacy/security and rule governing its use and disclosure

• Who must follow HIPPA:

  • Healthcare systems

  • Insurance companies

• Minimum Necessary Rule: PHI disclosure should be limited to the minimum necessary to accomplish intended purpose

  • Does not apply to Provider-to-Provider communication for treatment

• De-Identified information is not PH under HIPPA

HIPPA: Family Disclosures

• A genetic counselor cannot tell a patients family about test results unless given authorization

  • Verbal permission

• A patient doe not want to disclose reuslts to family

  • Explore → educate → identify barriers → facilitate disclosure

  • Provide ***FAMILY LETTER***

  • Offer to speak to them yourselves and get permission from patient

• Duty to Warn Disclosure: Only if there is serious and imminent threat to health or safety

HIPAA Disclosure: Post Mortem

• Patient dies: Disclosure of results to

  • Provider treating an at-risk relative for that relative's treatment

  • Family previously involved in the patient's care/payment

  • LEGALLY recognized Personal representative may have access/authorization authority

  • ***Known wishes of the deceased regarding family disclosure matter.***

Death does NOT end confidentiality, but HIPAA allows pathways for medically relevant genetic information to reach surviving relatives.

And the particularly board-worthy genetics point is:

A deceased person's genetic information may be disclosed to a healthcare provider treating an at-risk relative when relevant to that relative's treatment—HIPAA does not require authorization for that treatment disclosure.

Protected Health Information (PHI)

• Names

• Dates

• Telephone numbers

• Geographic data

Belmont Report Ethical RPincples

1. Respect for Persons; AUTONOMY

• People should be treated as autonomous decision makers

  • Informed consent

  • voluntary decision-making

  • non-directiveness

  • Board clue: “Whose decision is this?” → RESPECT FOR PERSONS

2. Beneficence

• Researchers should seek to maximize potential benefits and minimize potential harms

• “What produces the most benefit while minimizing harm?” → BENEFICENCE

3. Justice

• Participants should be treated fairly and the opportunity to participate should be given fairly

  • Fair and equitable access/treatment

  • Avoiding selection of research subjects simply because they're easily exploited

  • Ensuring underserved populations have reasonable access to genetic services

  • Fair distribution of research risks and benefits

ABGC 4 Princple Ethics

Principle	Meaning	GC example
Autonomy	Respect patient's decisions	Patient declines testing
Beneficence	Promote patient's welfare	Offer useful surveillance
Nonmaleficence	Avoid/minimize harm	Consider harms of unnecessary testing
Justice	Fairness/equity	Equal access to genetics