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Flexible ordering may unravel pay snags for respiratory panels

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Kevin B. O’Reilly

October 2015—The advantages of molecular respiratory viral panels are accompanied by a challenge for laboratories that find it difficult to secure payment for testing that can cost hundreds of dollars, depending on the number of pathogens involved.

These respiratory panels can create complications for laboratories that must juggle several platforms to meet clinician needs, spare patients from unnecessary out-of-pocket costs, and responsibly use lab resources. A newly cleared flexible respiratory testing panel could offer laboratories another approach.

Dr. Root

Dr. Root

“With traditional culture methods—and this is what payers are used to, as well as clinicians—you generally tested a small number of pathogens and then reflexed to more specific organisms when it was necessary,” Charles Root, PhD, said during a CAP TODAY webinar presented in cooperation with Nanosphere. “We’re now in a much different situation where we can test a lot of pathogens almost instantly in large screening panels. . . . But now the payers are saying, ‘Well, do I really need all that, or do I want to pay for it?’”

GenMark Diagnostics’ eSensor Respiratory Viral Panel, for example, can detect 14 respiratory virus types and subtypes. CPT code 87633 is used to report infectious agent detection by nucleic acid (DNA or RNA) for between 12 and 25 targets, said Dr. Root, CEO of Schaumburg, Ill.-based CodeMap, a firm that offers advice on coding, payment, and coverage for laboratory tests. Medicare will pay $567.18 for an RVP with that many targets.

That sort of eye-popping figure “sets the stage for some of the pushback that we’re beginning to see from payers,” Dr. Root said. “A $567 payment from Medicare or other payers tends to get their attention much more than one down in the $100 or $100-or-less range.”

While Medicare, he added, largely takes a pay-and-chase approach to reimbursement, pursuing testing alleged to be medically unnecessary after the fact through its audit process, private insurers “tend to be a little smarter than that and they react a little quicker.”

“The commercial payers are paying attention, especially to the six-to-11 and 12-to-25 target codes saying, ‘Well, these are not medically necessary. You don’t need all of those [targets], especially for low-risk populations,’” he said. “They want to see small, targeted panels that are the most likely to [find] the causative agent. And then reflexing to a larger panel only when it’s necessary, when you still have symptoms, but you’ve got a negative result.”

And that can mean a greater financial burden for patients, said Nathan Ledeboer, PhD, medical director of microbiology and molecular pathology at Wisconsin Diagnostic Laboratories, which is owned by Froedtert Health in Milwaukee.

Dr. Ledeboer

Dr. Ledeboer

“Patients, in many cases, are paying for laboratory-based diagnostics rather than insurance companies. And it means that patients have become much more cost-sensitive when insurance isn’t paying the overall bill. So clinicians are now also looking increasingly at cost to the patients, as well as patients looking at their own cost and whether testing should be done. And, again, the laboratory needs to be aware of this,” said Dr. Ledeboer, who spoke along with Dr. Root during the CAP TODAY webinar, which is available for viewing on demand at https://www.captodayonline.com/cap-today-hosted-webinars/#nanosphere.

RVPs also have added another layer of complexity and cost for laboratories, Dr. Ledeboer said.

“If you look at our laboratory just as one example, in order to meet the demands of all of our clinicians and to have all of our different panels that are available, we have to go to multiple vendors, which represents a challenge,” he said. “We use things from Alere, we use things from Cepheid, we use things from Quidel, from Nanosphere, from BioFire, from GenMark. We use a variety of different tests, and we assemble that into a broader array of different respiratory panels in order to make the optimum platforms or the optimal panels available to meet our clinicians’ needs.”

The laboratory also uses a lab-developed test for its Bordetella testing. That approach to respiratory testing offers flexibility for clinicians, but this versatility comes with its own set of headaches.

“If you break apart our current algorithm, the benefit is that we’re able to offer four orderable respiratory virus panels to our clinicians, giving them a great degree of flexibility in giving the patient the right diagnosis with the right number of tests being ordered,” said Dr. Ledeboer, associate professor of pathology at the Medical College of Wisconsin. “The limitation of our algorithm is that it complicates ordering. It requires multiple entries into our information systems. It’s costly because we have to have multiple reagents from multiple vendors. We have to maintain proficiency on all these systems. We have to show comparability between these systems. And they require space.”

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