Trends in reimbursement for reproductive genetic counseling by multiple payers from 2010-2018

Francesca M. Spinosi
In 2007, the implementation of CPT code 96040 for "Medical Genetics and Genetic Counseling Services" allowed genetic counselors to bill directly for services and to regulate genetic counseling reimbursement. Lack of insurance coverage is a barrier of access to care for patients that needs to be addressed. This retrospective study examined reimbursement of reproductive genetic counseling encounters billed under 96040 at Rutgers Robert Wood Johnson Medical School, a regional perinatal center in
more » ... rinatal center in New Jersey, a state requiring licensure. Descriptive statistics were tabulated to assess the difference between payer categories, (Medicare/Medicaid, Managed Care Medicaid, and commercial insurance), including how often encounters were reimbursed and if reimbursed, at what percentage of the amount billed. For commercial payers, a comparison of individual plan types (Health Maintenance Organization, Point of Service, and Preferred Provider Organization) was carried out. Trends in reimbursement were assessed over the eight-year period for payer types. The study found that 61% of 60-minute encounters billed under 96040 were given any reimbursement. Of reimbursed encounters, the payer reimbursed only 36% of the amount billed. Medicare/Medicaid encounters were never reimbursed as the Centers for Medicare and Medicaid Services (CMS) do not recognize genetic counselors as credentialed providers nor recognize 96040. Commercial insurance reimbursed most often at 65% of encounters, but varied greatly between payer and individual plan type. There was an overall downward trend of the percentage of encounters reimbursed over the eight-year period. In order to improve payer reimbursement, consistent infrastructure needs to be created for each payer type. While this has started with the introduction H.R 7083, "Access to Genetic Counselor Services Act of 2018" to recognize genetic counselors as CMS providers, the need is still present for other payers. If genetic counselors were deemed in-network providers for commercial payers, reimburseme [...]
doi:10.7282/t3-cg2y-5g34 fatcat:zravjasglje4xi2rk5dyoar4by