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Genetic Counselors Group Crafting Legislation to Garner Medicare Provider Status

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By Turna Ray

The National Society of Genetic Counselors
is working to introduce new legislation in Congress within the next month proposing that the Centers for Medicare & Medicaid Services reimburse for genetic counseling services for Medicare beneficiaries.

"Genetic counselors are not currently recognized by Medicare as providers like most other healthcare professionals are," Elizabeth Kearney, president-elect of NSGC, told Pharmacogenomics Reporter this week. "We want legislation to correct that so CMS does recognize genetic counselors as providers, with the intent of increasing access to genetic counseling services for Medicare beneficiaries."

The NSGC represents approximately 2,400 genetic counseling professionals. Most NSGC-member counselors work in patient care, providing education to patients and families who have a particular genetic risk. However, Kearney noted that increasingly counselors are expanding into other areas, within public policy or industry.

As a group, "this is really our first effort at being recognized by Medicare" through the legislative process, Kearney said. Only through an act of Congress can a currently unrecognized professional group, such as genetic counselors, become a provider of reimbursable services under Medicare.

NSGC has a working draft of the legislation, and has had discussions with members of Congress who have shown interest in sponsoring the bill. Any resulting legislation focused on garnering provider status for genetic counselors will likely be separate from the overall healthcare reform bill currently being considered by Congress.

Under current CPT rules, licensed doctors providing genetic counseling can seek reimbursement through CMS for genetic counseling services provided to Medicare beneficiaries, but genetic counselors who are not MDs cannot.

However, in terms of private insurance, the situation for genetic counselors has improved somewhat. In recent years, the American Medical Association has introduced a new CPT code (96040) to cover genetic counselor-only visits from private payors. Still, the reimbursement rates are not as high as when a licensed physician is present during the genetic counseling session.

For three months in 2007, researchers at Northwestern University reviewed billing statements and account information from patients who sought genetic counseling at the School of Medicine's OB/GYN department to monitor the extent to which genetic counselor-only sessions were reimbursed by private insurers.

During this period, genetic counseling services were provided by genetic counselors with and without the presence of a licensed physician in Northwestern University's Division of Reproductive Genetics. Counseling services were provided for prenatal diagnosis and screening, as well as to families with hereditary gynecological cancer risks.

Although researchers found that "most private insurance carriers are paying for genetic counselor-only visits … reimbursement for physician-attended [evaluation and management] consultations is much higher."

In crafting legislation and gathering materials to make its case to Congress, Kearney noted that the NSGC has had difficulty gathering figures and case studies for when the lack of Medicare coverage of genetic counseling services has led to inaccurate testing or unnecessary costs for payors, since such data is usually proprietary to commercial firms.

An official from United Healthcare recently said at a conference that the lack of patient and physician education is what often leads to unnecessary testing or inaccurate interpretation of tests, and provided several examples [see PGx Reporter 08-12-09]. The national payor recently began providing covered genetic counseling services for enrollees requesting BRCA testing.

The HHS Secretary Advisory Committee on Genetics, Health, and Society have formed a task force to promulgate recommendations to improve the educational and training needs of the genetic healthcare providers. The integration, education, and federal recognition of genetic counselors are focus areas of this task force.

Kearney said that the NSGC has been actively collaborating with SACGHS to make the needs of genetic counselors known to government healthcare regulators.

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