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Genetic Counselors Push to Advance Legislation to Allow Medicare Billing


NEW YORK (GenomeWeb) – After years of trying, the National Society of Genetic Counselors succeeded last week in getting some US legislators to recognize the positive impact the profession has on the cost and quality of patient care, and to introduce a bill that would allow certified genetic counselors to charge Medicare for their services.  

H.R. 7083, or the "Access to Genetic Counselor Services Act," would amend the Social Security Act to cover genetic counseling services when furnished by a state-licensed genetic counselor. For genetic counselors working in states that don't have licensure requirements, the legislation would have the HHS secretary establish criteria that they could meet in order to bill Medicare. The legislation also contains payment and coding provisions specific to Medicare billing for genetic counselors.

Andrea Forman, who has been a genetic counselor for 14 years, recalled that every year at the NSGC annual meeting there would be talk of how there was a draft bill or how lobbyists for the group had been encouraging conversations on Capitol Hill about this issue, but these efforts never seemed to go anywhere.

"We've waited a long time for this," said Forman, senior genetic counselor at Fox Chase Cancer Center, who estimated that 20 percent of the cancer patients she sees have Medicare coverage. "This is the farthest we've ever gone."

Currently, the Centers for Medicare & Medicaid Services don't recognize genetic counselors as healthcare providers. H.R. 7083 would require genetic counselors' services to be covered in the same way these services are covered when provided by a physician.

NSGC President Erica Ramos said that the group has been pushing to get CMS recognition for the profession for the last six to seven years. The bill is co-sponsored by Congressmen Erik Paulsen (R-Minn.) and Dave Loebsack (D-Iowa) and referred to the House Ways & Means Committee and the House Energy & Commerce Committee.

"What was helpful this time around when we put it in front of the representatives was that we now have even more evidence that [using] genetic counselors would be cost-saving for CMS," Ramos said.

Genetic counselors help patients and physicians understand hereditary diseases that affect them and their families. They also help interpret genetic test results and explain how those results could impact prevention and treatment. In recent years, as researchers have elucidated the role of genetics in more and more diseases, the demand for genetic counselors has increased, especially those with specialized knowledge in disease areas like cancer, cardiovascular disease, and neurological illnesses.

Meanwhile, CMS and commercial payors, noting a significant uptick in their payments for genetic tests, have begun tracking and reining in what they perceive to be inappropriate utilization. Concert Genetics, which uses data analytics to provide insights into the genetic testing market, estimated that there are more than 74,000 commercially available tests in the US and 14 new tests entering the market daily. The firm's recent analysis also suggests that the amount insurers spend on genetic testing has been increasing by 25 percent to 75 percent, without much insight into whether those tests improve patient outcomes.

NSGC has tried to make the case to legislators that genetic counselors could help in this regard if they were recognized by CMS. The society commissioned healthcare consulting firm Dobson, DaVanzo & Associates to conduct a health economics analysis, which found that genetic counselors could save the government money in two ways: by reducing inappropriate testing and by performing counseling services at a lower rate than physicians.

The study, which relied on interviews, published data, and a claims analysis, projected $4 billion in potential Medicare savings over a decade if certified genetic counselors were to help patients and physicians determine which tests to order, based on their evaluation of the available evidence. Moreover, when genetic counselors provide such services, they are reimbursed at 85 percent of the fee that physicians get for the same services. If genetic counselors were able to bill Medicare for their services, those lower rates could lead to potential Medicare savings of $50.7 million over a decade, the study estimated.

Based on this data, H.R. 7083 would also allow genetic counselors to be paid at 85 percent of the actual charge for the service or the physician fee rate for the same service (whichever is the lower rate.)

The bill comes at a time when insurers, spurred by the uptick in genetic testing utilization, are increasingly instituting prior authorization programs that require patients to receive independent pre-test genetic counseling in order to garner coverage for certain tests. However, when UnitedHealthcare stipulated such a requirement for BRCA testing a few years ago, the American College of Obstetricians and Gynecologists and the American Congress of Obstetricians and Gynecologists (ACOG) objected that this would negatively impact patient access to necessary tests.

ACOG asserted that Ob/Gyns are skilled in evaluating a woman's medical and family history, providing pre- and post-test counseling, and ordering appropriate genetic testing. UHC's latest policy on hereditary cancer testing now "strongly recommends" genetic counseling, although the insurer also mentions that pre-test counseling should "be done by an independent genetic care provider who isn't employed by a genetic testing lab."

Ramos hopes that provider groups will not perceive H.R. 7083 as an effort to hinder qualified healthcare practitioners from counseling their patients. She pointed out that the bill specifically states that its provisions "shall not be construed as preventing other practitioners, including those providing telehealth services, from providing covered genetic counseling services within the scope of their practice.''

"The goal of this bill is by no means to take away the opportunity to provide genetic counseling services from trained physicians [and] nurse practitioners," Ramos said. "It's really to ensure that practitioners who are not willing or able or comfortable providing these services have genetic counselors who can work with them, and are accessible to them and their patients."

For genetic counselors, the fight for CMS recognition and payment is inextricably tied to patient access. Genetic counselors want patients to have appropriate testing and accurate information about their diseases, but they also have to prove their worth to the institutions they work for, Forman reflected.

At Fox Chase, because genetic counselors can't bill Medicare directly, the cancer center used to ask patients to cover the cost of the sessions. For patients who couldn't afford counseling and met criteria for financial assistance, the cancer center had a grant that allowed it to pick up the tab for the sessions. But many patients refused counseling when they realized there may be an out-of-pocket cost, even before Fox Chase could offer financial support, Forman recalled.

Recently, the cancer center decided that it would no longer bill Medicare for genetic counseling visits. "Professionally, it can be difficult to show your value to the administration at your hospital, when you can't even bring in revenue that comes close to covering the cost of a salary," she said.

Currently, genetic counselors are billing insurers in a number of ways. In a 2017 NSGC survey, 59 percent of direct patient care genetic counselors said they were able to bill for their services. For in-person counseling sessions, 24 percent indicated they bill commercial insurers under their own name, 31 percent said their services were covered under a facility fee, and 4 percent said they work for institutions that use a bundled fee, which is a combined charge for the genetic counselor's and the provider's services.

In the survey, 35 percent said they bill for in-person counseling sessions under a supervising MD's name, which is the most common way genetic counselors work around the restrictions on directly billing Medicare. "There are very specific rules around how this type of billing can be implemented, and it's far more costly, because it includes the provider fee as well," Ramos said. "That's not an ideal use of money or resources for Medicare beneficiaries."

Given there were around 57 million Medicare beneficiaries as of 2016, the alternative, that genetic counselors don't bill Medicare at all, also isn't sustainable to the profession. "That's a huge proportion of the healthcare spend in this country and a huge proportion of people who are covered," she noted.

For example, 25 states have licensing requirements for genetic counselors, which means they can directly bill insurers. But because genetic counselors can't bill Medicare, some healthcare systems in these states don't bother credentialing them, even if they could. "If you can't bill Medicare, they don't really look at it as being significant," Ramos explained.

Genetic counselors can use CPT code 96040 to directly bill for 30-minute increments of "medical genetics and genetic counseling services," covering activities like taking a family's history of a disease, assessing a patient's genetic risk for a condition, and counseling patients and their family members. While commercial payors allow genetic counselors to bill using this code, CMS currently doesn't pay for this code.

H.R. 7083 would establish a modifier, to be used with evaluation and management CPT codes that only genetic counselor would use. While CPT code 96040 can be billed by a variety of healthcare providers and genetic counselors, "this modifier would indicate that this was a service provided by a genetic counselor," Ramos said.

While the introduction of H.R. 7083 is a long-sought achievement for NSGC, it's hard to predict how far the bill will go ahead of upcoming congressional elections in November. Notably, the bill has bipartisan sponsorship.

"If analysis by the Congressional Budget Office matches what we've been seeing from our independent assessments, genetic counselor recognition has the ability to save Medicare a significant amount of money," Ramos said. "We certainly hope that's a bipartisan issue, but also, care of patients is a bipartisan issue."

In the years NSGC has lobbied for a legislative fix to the Medicare billing problem, the 3,600-member organization has had to vie with bigger professional societies for legislators' attention. While seeing CMS recognition, the society has also had to raise awareness of the profession in a politically divided Congress that has been unable to advance legislation on topics that both sides of the aisle have historically supported.

"Let's face it. Lawmakers are inundated by lobbyists, and we're such a small group of people," Forman said, adding that "if anything, it's probably indifference on the part of politicians" that's kept this bill from being introduced until now.

Genetic counselors' historic role in the prenatal setting may have also been politically disadvantageous. Since the genetic counseling profession took off in the area of prenatal testing in the 1970s, when amniocentesis and ultrasound technologies first became available, some have viewed genetic counselors as the people who tell women they need to have an abortion when there is a genetic abnormality in the fetus. This is not what genetic counselors do, Forman said, but nonetheless, it is a misconception that some hold.

This stigma may be dissipating now that genetic testing is increasingly integrated in other healthcare settings, particularly in cancer care, where genetic counselors are in high demand. "Cancer is a topic that touches every political stripe, every gender, every race," Forman said. "The [genetic testing] field is evolving, and its utilization is expanding. This may be helping make genetic counseling a more politically palatable topic."