Seattle Children’s Hospital (SCH) implemented a laboratory test stewardship program with focus on genetic testing in 2012. Key to the program has been the hospital’s ability to standardize the prior authorization process and integrate it with the test stewardship review program. Given genetic testing’s relative cost and evolving coverage policies, aligning test requests with payer requirements has been critical to reducing financial liability for patients, families, and the institution (1).
However, annual surveys revealed that providers were frustrated with the insurance authorization process, specifically with the burden of navigating denials and appeals. For example, one respondent commented that “sometimes it takes time to get the paperwork with the [denial] reason … and what a provider may do to appeal the denial isn’t always clear.”
In the spirit of continuous performance improvement, we sought to improve the current denial and appeal process through targeted interventions to support providers and their teams, and ultimately increase the likelihood of a successful appeal.
Defining the Problem
Coverage of a genetic test is based upon the policies and the specific benefit structure of a patient’s health plan. Common reasons for denials include not medically necessary (NMN) and investigational/experimental (I/E) (2). Understanding the specific denial reason and tailoring the appeal accordingly helps prioritize the efforts of busy teams. It also informs communication with patients about what to expect.
An appeal letter demonstrating how a patient fits the policy is effective when the denial reason is NMN because it addresses details that the payer may have lacked in its initial review. Payers are less likely to overturn denials for other reasons, such as I/E. Other denials simply are not appealable. For example, if a request is denied because genetic testing is not a covered benefit, no amount of persuasion will change the outcome.
We completed a baseline assessment via interviews with staff and providers within departments that coordinate a high volume of genetic test requests, including both genetics and nongenetics specialties. This revealed a gap in understanding about the implications of the denial reason and how to target appeals accordingly. In fact, providers were appealing genetic testing denials mostly in a test-specific or disease-specific manner, rather than focusing on the denial reason and policy.
We discovered that the reason for their approach was an entrenched library of appeal letter templates that had accreted over years. Filling out these templates is time-consuming, resulting in lengthy letters that feature abundant clinical detail and references to the literature—but a scattershot approach to arguing medical necessity. Unfortunately, the letters often did not end up addressing the specific coverage policy nor the reasons why the insurance company denied the test. This is neither efficient nor effective.
Our interviews also revealed that letter writers often did not review the payer’s denial letter containing the denial reason and policy details. Some letter writers did not know to look for the denial letter. Others found it cumbersome to locate the letter in the electronic medical record (EMR) and so proceeded to compose appeals without referencing the denial information. Even with the letter in hand, they lacked guidance to translate the denial information into an effective appeal.
Over the past 2 years, the laboratory genetic counseling (LabGC) team piloted appeals guidance for genetic testing denials ordered by teams without clinical genetics expertise and support. This guidance focused on tailoring appeals based upon the denial reason. For example, in the case of a NMN denial, the LabGC team would review the specific insurance policy and the clinical features of the patient and help the provider focus the appeal on why the patient fit the policy or was otherwise exceptional.
Comparing the appeals success rate and completion rate between the LabGC-supported, nongenetics group and the genetics group yielded further insights to iterate the intervention. As expected, NMN and I/E were by far the most common denial reasons (52% and 44%, respectively), with similar frequency across both groups. LabGC support improved appeals success when compared with genetics group appeals for both NMN (51% vs. 33%) and I/E (12% vs. 10%) denials.
Despite support, there remained a gap in the appeals completion rate between the nongenetics and genetics groups (approximately 70% vs. 90%, respectively). Teams still needed to take action to complete the appeal, and reported confusion about next steps, difficulties transforming the guidance into an appeal letter, and integrating the guidance with existing letter templates.
Tailoring the Intervention
Building on these experiences, we collaborated with the teams to develop and implement additional supports to make it as easy as possible to complete effective appeals. This dialogue also served as an opportunity to continue to educate the teams.
Teams needed to be able to identify the denial reason quickly and easily. We developed a job to aid providers find denial letters in the HER, and in collaboration with the Insurance Processing Department, modified the insurance outcome notifications to include a call-out box highlighting the denial reason and accompanying policy. We also modified the notifications for approvals and denials that cannot be appealed.
To help demystify the insurance jargon, we created a new quick reference document with general guidance organized by denial reasons and a short explanation about what to do next (Table 1). This document is directly linked from insurance outcome notifications, improving visibility and ease of access.
The LabGC review and case-by-case guidance expanded to support all genetic testing denials, not just those ordered by nongenetics teams. The suggestions are attached to the insurance outcome notification and build upon the principles laid out in the general guidance, ensuring the need-to-know information comes to teams in one communication.
We also created letter templates with prompts to transform that information into effective appeal letters. These included prompts by denial reason to help providers focus on the important information they needed to include and to serve as a repository to incorporate the LabGC guidance. The templates are posted on our institution's laboratory stewardship website for teams to easily access and modify.
Measuring Success
Since implementing the new tools and process, we have received positive feedback. A check-in with teams from the high-volume specialties indicated improved awareness of the support tools, improved assessment of communication clarity, and better overall satisfaction with the denials and appeals process. At this time, because of the inherent lag in insurance companies responding to appeals, we are not yet able to assess the impact on denials overturned.
Our teams benefit from getting the key information from denial letters extracted and highlighted in the insurance outcome notification and gaining additional insights from LabGC review. This may not be possible in all clinical practices. Nevertheless, the core principles of identifying the denial reason and tailoring an appeals letter to specifically address it still apply. These insights about the denials and appeals process should help clinical teams be more efficient and effective.
References
- Mathias PC, Conta JH, Konnick EQ, et al. Preventing genetic testing order errors with a laboratory utilization management program. Am J Clin Pathol 2016;146:221−6.
- Washington State. Office of the Insurance Commissioner. Common reasons for a denial and examples of appeal letters. https://www.insurance.wa.gov/common-reasons-denial-and-examples-appeal-letters (Accessed May 2022).
Sam Huang, MD, is a physician in medical genetics at Marshfield Clinic in Marshfield, Wisconsin. +Email: [email protected]
Jessie Conta, MS, LGC, is manager of the Laboratory Genetic Counselor Team at Seattle Children’s Hospital. +Email: [email protected]