Insurance Alignment

Overview:

A primary initiative of PLUGS is insurance alignment. Our efforts focus on relationship-building and increasing awareness of the challenges faced by providers, labs, patients, and payers. Alignment requires the achievement of three related goals:

      1. Better medical policies that can be used by both clinical labs and payers, and understood by patients.
      2. Reduction of administrative burden for all parties, and
      3. Proper documentation – in both the medical record and in documentation submitted to payers – so that patients properly understand when complex testing is a covered benefit and how to access that benefit.

If you are a patient or caregiver please see additional resources here.

Medical Policies:

The following PLUGS® policies were developed by experts within the PLUGS network and are intended for use by insurance payers, laboratories, providers, families, and consumer groups to guide coverage and reimbursement for medically appropriate genetic tests. Microsoft Word versions available upon request.

Tools for Providers

The following tools are intended to help providers, laboratory administration staff, and others navigate the preauthorization process at their institutions while adhering to payer policies and utilizing available resources. The tools were created by a working group within the PLUGS Insurance Alignment Committee.


Insurance Alignment Committee

The Committee formed to create and share best practices related to insurance alignment, including preauthorization workflows, appeal guidance, billing and coding, and medical policy. The three working groups include engaged members from the PLUGS network who represent a diverse set of perspectives. 

Jodie Vento, MGC, LCGC
Committee Chair

Manager, Center for Rare Disease Therapy
Genetic Counseling Supervisor, Laboratory Services
Children’s Hospital of Pittsburgh of UPMC

Working Groups:

CPT Code Working Group:

Goals/projects: Work with team through process of obtaining epilepsy CPT code.  Learn together so that members can successfully obtain other CPT codes. Encourage collaboration across labs, clinicians and professional societies.

Progress: Epilepsy panel GSP code approved, will appear in 2021 CPT code book. 

Preauthorization Toolkit Work Group:

Goals/projects:  Gather best practices and create a toolkit that will help laboratorians and providers navigate insurance preauthorization processes, adhere to payer policies, support appeals for medically appropriate tests, while integrating stewardship principles.

Progress: Comprehensive toolkit created and available to PLUGS members, with selected resources publicly available to providers.

Medical Policy Working Group:

Goals/projects: Promote communication and relationships with payers; present at payer summits, state payer meetings; review medical policies developed by other PLUGS groups; and serve as a resource for other PLUGS groups.


Stewardship Standards:

Appropriate utilization of clinical laboratory services is important for patient care and requires institutional stewardship. Clinical laboratory stewardship programs are dedicated to improving the ordering, retrieval, and interpretation of appropriate laboratory tests. In addition, these programs focus on developing, maintaining, and improving systems to provide proper financial coverage for medically necessary testing. Overall, clinical laboratory stewardship programs help clinicians improve the quality of patient care while reducing costs to patients, hospitals, and health systems. 

Learn more about stewardship standards and the National Committee for Laboratory Stewardship.