Molecular Genetics Test and Price List Massively Parallel Sequencing ... consent for genetic testing from the patient/ parent/ guardian must be obtained prior to testing and a copy ... ($2,500 total cost). That’s what we all want to pay for anyway. Please indicate on the referral if this is not required. This is actually closer to where I would expect to see the price for this service in my anecdotal but valid experience. But in healthcare, for me, it’s almost easier to understand the granular level micro examples than the macroeconomic issues. Molecular genetic testing is almost as complicated as the pricing for the service itself. We are talking some pretty scientific stuff here. The gap between what my insurance and Medicare are each willing to pay for this service is over $1,000. I should also mention, each CPT code can map to more than one charge line and even have a different price. The “consumer-friendly” description of this is a translocation analysis (BCR/ABL1) major breakpoint. The resulting BCR-ABL fusion gene from this translocation creates an enzyme that is not regulated appropriately (active when it shouldn’t be). They provide a description and the CPT code and it makes everything much easier to understand. We can save $12-$15 on this test if you are willing to drive across town. This means that we often ask the patient to pay for all or part of the cost of the test, whether or not there is a Medicare rebate. It is basically looking for a mutation of the BCR/ABL1 gene often found in patients diagnosed with chronic myelogenous leukemia (CML). Unfortunately, it can be hard to pin the cost down on some of these more complicated tests depending on the setting and overhead that runs through a laboratory. Your email address will not be published. If you need a mastermind to join your finance team, please reach out. Then there is always the “reference” lab route. Max happens to know that is far from the case. The test we are going to talk about today is pretty amazing. To be fair, there were some copyright concerns around the industry on whether or not they could publish CPT codes online. Price strategy committees are popping up. But except for government payers, there is technically nothing mandating a price cap for this service for commercial carriers or uninsured patients. Price would be the last thing on my mind. With just one lab test, I am going to demonstrate how complicated healthcare reimbursement has become. Your PCR test- CPT 81206 can look at this molecular response. I am very happy there are people out there much smarter than Max who have figured all this out. That’s a whole other blog post I will never write. CPT code 81206 represents this particular test. CPT code 81206 represents this particular test. I like the idea of packaging some of this stuff up and paying a “fixed fee” to manage a problem for several months/years. Always consult with a certified professional before making any financial decisions. If I had cancer, I would likely take the path of least resistance to get this test as quickly as possible. They used this sample to determine their pricing effective 1/1/2018. Lastly, some hospitals like Johnson Memorial Hospital go above and beyond. I highlighted the two that probably meet the definition of this test. So, the test can be used in diagnosis and monitoring. ‘Protecting Access To Medicare Act of 2014’. These internet encounters often spark questions about how much something costs. Throw in a strong bonus incentive for positive clinical outcomes. Tags: 81206BCR/ABL1CHARGEMASTERchronic myelogenous leukemiaCMLPCR. Personally, I don’t think “itemized healthcare” is going to be the model of the future. Where Do I Keep All Of These Medical Office Buildings? In theory, the retail pricing for this test would be set by the “competitive” commercial insurance market. You can’t put a price on remission. The cost increases if more than one test is necessary or if multiple family members must be tested to obtain a meaningful result. For the tests that are covered by Medicare, the rebate provided is often less than the cost to us of providing the test. I have nothing but good things to say about your organization. We can pretty easily see that Medicare pays $163.96 for this particular form of molecular genetic testing. Apparently, this fusion gene can predispose an individual to certain cancers. I am on a high deductible plan, so that would initially all come out of my pocket until I hit my $6,600 max out-of-pocket. So, in my relatively short career, even I have seen some pretty wild swings for this particular lab test. Molecular testing is capable of detecting active COVID-19 infections in the human body. Again, a small assumption on this since they don’t share the CPT code. That’s on top of the $20,000 in premiums me and my employer dump into the system every year, a number the dwarfs my annual budget. My price can’t be greater than the hospital charge, though. The 50th percentile price would come in around $500 and about $780 for the 75th percentile. It can check for the presence of the mutant cancer gene at very low levels. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window). Here are the two options from Beaumont Hospital System’s chargemaster in Michigan for this particular service. But in the end, my ultimate stakeholder is the patient, and we owe it to them to simplify this mess. The big problem is most of them did not include the CPT code on their listing which is one of the easier ways to communicate complex medical terminology. Genetic testing typically is covered by health insurance when recommended by the patient's doctor. Thankfully, I know how to work my way through the call centers and price transparency websites. Unfortunately, the system currently is set up with various price points on the way to remission. Frankly, I work in the industry and I really don’t have a basis for pricing this molecular genetic test outside of the data the Medicare program has developed. It’s a mouth full. Apparently, it’s time to take things to the next level. Welcome to PathWest’s Diagnostic Genomics Laboratory. But going through this process for the other 1,655 lab tests currently listed on the 2020 Medicare Clinical Diagnostic Laboratory Fee Schedule would take some time. I don’t blame individual insurance companies or hospitals for where we are today. My understanding is the BCR gene has three different regions referred to as “major”, “minor”, and “other points”. We recognise that this will not be easy for many patients and families. Again, I will leave the clinical difference to the oncologists. What I find interesting about these prices is as of 1/1/2018, most of them are derived from the weighted median private insurance payer rates. My understanding is a patient getting treated for CML might need to have this test several times per year to help monitor the tyrosine kinase inhibitor treatment/therapy for CML. Speaking to my experience, I have personally seen 81206 charged anywhere from about $150 to $700 depending on the hospital. If we have an oncologist reading this, feel free to break this down into layman’s terms for people like me. "Genetic testing is cost-effective as it allows clinicians to prescribe chemotherapy in a tumor-specific manner. Feel free to skip the next paragraph if you can’t handle a few technical terms. Max can get pretty micro when talking about healthcare economics and how pricing is currently set up. I also happen to know my own personal insurance company has negotiated this test down to a maximum charge of about $1,200 at a few of my local hospitals. They may be spreading their cost differently than Beaumont or practicing cost-shifting. Back in 2017, this same test had a national payment limit of $224.91, so evidently this new method of pricing reduced reimbursement for this lab. It can check for the presence of the mutant cancer gene at very low levels. Hopefully, this explanation is not too dense. For patients not covered by health insurance, genetic testing cost ranges from less than $300-$3,000 or more, depending on the individual, the type of test and the comprehensiveness of the test. I am glad you also clarified on the “qualitative” vs. “quantitative” as my wife if an AP statistics teacher and was questioning how that was being used in this context.

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