Reimagining laboratory benefit management

Joanne:

Hello, and welcome to today's webinar, Reimagining Laboratory Benefit Management. Before we get started, I'd like to review a few housekeeping details. Today's webinar is being recorded, and an online archive of today's event will be available within one to two business days. If you have trouble seeing the slides at any time during the presentation, please press F5 to refresh your screen on a PC or command R if you're using a Mac.

Joanne:

You may ask a question at any time during the presentation by typing your question into the Q&A box at the right side of your screen and pressing enter. And finally, I'd like to remind you of a [inaudible 00:00:39] antitrust statement located in the link just below the slide viewer. We will, as always, comply with that statement. Among other things, the antitrust statement prohibits us from discussing competitively sensitive information.

Joanne:

We're very fortunate to have with us today John Hoffman, Tanya Hendrickson, and Dr. Rahul Singal. John is vice president of the payer market for Optum. Prior to his current position, he led one of Optum's payer software and managed services businesses, and prior to that, held various operational leadership roles, leading service delivery functions, working with both Optum's health plan and provider customers.

Joanne:

Tanya is strategic product director for Optum. In this role, she focuses on building innovative new offerings to drive medical cost savings initiatives. Tanya has 20 years of experience in product management and has worked in both provider and payer software businesses.

Joanne:

Dr. Singal joined Avalon Healthcare Solutions as its chief medical officer in 2021. He has more than 20 years of healthcare experience as a scientist, practicing internist, health plan medical director, and healthcare information technology entrepreneur. And at this time, I'd like to turn the floor over to the speakers.

John Hoffman:

Great. Thanks, Joanne. My name is John Hoffman. Thank you, everyone, for coming to our session today around reimagining laboratory benefit management. I'll go ahead and give you an overview of some of the laboratory market highlights and give you some background on Optum's collaboration with Avalon Healthcare Solutions. And then Tanya and Rahul will walk you through in more detail the specifics around our combined solution, really highlighting the routine test management program and the genetic test management program. And then we'll leave some time towards the end for some Q&A through the chat function here.

John Hoffman:

So we'll get into it. Here's the great news. So from the mapping of the human genome 20 years ago to the emergence of direct to consumer genetic testing, companies like 23andme, there's some incredible advancements underway that really will change the way we detect and treat disease. So as a result of this scientific advancement, there's just an incredible number of tests that are now administered annually, somewhere in the neighborhood of 13 billion tests. And when it comes to genetics, there's something like 10 new tests coming to market every single day. So this is incredibly exciting. It gives us all a huge opportunity to learn more about ourselves and our members than ever before. It really can be overwhelming for consumers, labs, providers, and health plans.

John Hoffman:

So as a result of all this scientific discovery and the explosion of tests in the market, here are really the core challenges the industry is facing. By some studies, 30% of lab tests are unnecessary. That's an incredible amount of waste in the system. In the genetic space, there's another percentage of tests that simply have no clinical utility or validity, meaning they are in some cases useless and can result in false positives.

John Hoffman:

So when you combine that with the fact that 70% of medical decisions are based on lab results, things can get pretty scary. If you think about a complex genetic disorder or a complex cancer, it can really send you down the wrong treatment path, which can have horrible consequences for patients. So you couple that with the fact that there are some 75,000, by some studies, up to 100,000 different kinds of genetic tests in the market today, with only three to 400 corresponding CPT codes, how does a health plan have any idea what to cover, what to pay for, and what to pay for it?

John Hoffman:

So we're dealing with the high cost, complex genetic tests, identifying genetic diseases, which has huge implications for member treatment plans. But we're also dealing with the administrative complexity of ensuring that the right tests are covered, and those tests are valid and useful, and a health plan knows how to process a claim.

John Hoffman:

To kind of the last point on this slide before we move on, it's really easy to focus on genetics since the tests are typically for very high cost, very complex diseases. But it's important to remember that some 99% of all lab tests are routine tests. So when it comes to routine tests, just going to beat up providers and labs on further unit cost discounts really isn't going to work anymore. It really requires a multi-pronged approach to not only manage unit costs, but really manage utilization and know what you're paying for.

John Hoffman:

So this really brings us to our collaboration with Avalon Healthcare Solutions. So more and more over the past few years, our customers have been coming to us to say, "Hey, Optum, what can you do for me with respect to my rising lab spend and these complex genetic tests?" So we started the journey of looking into what's it going to take to build something internally. And we quickly realized, you know what, that is a multi-year effort. We're probably better off in going out and finding industry experts to partner with in this space.

John Hoffman:

We interviewed really all the major players in both the core lab benefit management space, as well as the genetic space. And it really led us to two partnerships with two companies that really rose to the cream of the crop, if you will. So two partnerships executed in 2021, one with Palmetto GBA, which is a regional MAC and an innovative company, and of course the other with Avalon Healthcare Solutions, which we're presenting here with today to talk about our combined solutions.

John Hoffman:

So if you really think about what the combined assets between Optum, Avalon, and Palmetto entail, you see it here on the screen. So you combine Avalon Solutions around their preferred lab network, their clinical policies, their automated policy enforcement tool, with Palmetto's assets around their technical assessment process, genetics codification system, which we'll talk about here in a little bit, and then Optum assets as far as our footprint with respect to all the integrations we have with health plans across the country. And you really have a combined holistic lab benefit management solution that we'll dive into here more in detail in a little bit.

John Hoffman:

Kind of the last piece on this, I want to mention the seamless integration with respect to this combined solution. So Optum has prepayment assets installed at over a hundred health plans throughout the country, either through our claims editing platform or our prepay audit platform. So we've developed an integration between the Palmetto content, Avalon's tools, with these assets to really reduce the technical lift our customers need to take on in order to make this product live in their environment.

John Hoffman:

So most of the work is on the Optum, Avalon side. In situations where a customer already has our assets installed, we can sort of piggyback onto that asset to really reduce that technical lift for our customers. As any health plan knows, installing something new prepayment can be quite a lift. So the fact that we've got these assets already installed and we can kind of plug Avalon onto the back of them really reduces the speed to value and reduces the lift a customer has to take on as far as IT resources.

John Hoffman:

So you see on the screen, some of the items in blue are where the Avalon Optum combination fits into the existing prepayment ecosystem, and we can talk more about that at a later time, but it gives you a feel for how that fits into the existing workflow. So at this point, I'm going to turn it over to Rahul to talk more about our routine test management offering.

Dr. Rahul Singal:

Well, thank you, John. So what I'd first like to do is kick off with the high level view of laboratory expenses. Sorry, advanced a little bit too far there. So when you step back and think about laboratory expenses, it runs around 20, $25 per member per month, with about 20% of the expenses, or four dollars per member per month, on genetic test spend, and then $20 on routine spend. And routine, the way we define routine, not genetic and not prior off necessarily, but it's your common test, your cholesterols, your vitamin Ds, your vitamin B12s, your thyroids.

Dr. Rahul Singal:

It also includes PCR testing or molecular diagnostic. Those are still routine. We're not looking at human DNA sequencing, is kind of how we think about genetic spend. And genetic spend generally needs historically prior authorization. And Tanya's going to go a lot deeper into genetic spend and how we collectively manage that.

Dr. Rahul Singal:

When you look at some of the metrics between routine and genetic, obviously routine, much more common, about four tests per member per year. That doesn't mean that each member goes to the laboratory four times. Many times when you go to the lab, you might get a cholesterol, you might get a whole lipid panel. Lipid panel alone will have four units. You might get a complete blood count, you may get a chemistry panel.

Dr. Rahul Singal:

The average price for each test is about $60, compared to genetic, where you're having one genetic test for every 30 members per year. Average cost is significantly more at 800. The price difference, as John had mentioned earlier, it's often two to 3X. So the range, 100 to 500 plus percent between an independent lab, that's a lot cheaper. The larger independent labs, Quest and Lab Corp, versus the hospital care setting. Genetic tests, there's not as much price difference between the independent genetic labs and hospitals. The hospitals would often outsource those to the independent labs that are not really allowed to take a mark up.

Dr. Rahul Singal:

Our savings, so on the Avalon Optum Lab Benefit Management Program, our savings on routine tests is eight to 10%. And remember, though, that's on a $20 per member per month. So the savings is upwards of a dollar, approaching two dollars per member per month. And that's very predictable. I like to say, you can take that to the bank. And then genetic test spend, it's a higher percentage, but lower total bucket of four dollars per member per month.

Dr. Rahul Singal:

So here's an example of how the program works for routine test management. So taking a member journey, a person goes in in their forties or fifties and goes in for an annual checkup, and one of the tests that the physician thinks they ought to order is to check their thyroid. And really the main test a physician wants is a TSH, or thyroid stimulating hormone. It's often not on the form. You could write it in. So the doc's like, "Hey, look, you're contracted with this lab. It's part of your insurance carrier. And I see thyroid profile. Let me check that. I'm very accustomed to it."

Dr. Rahul Singal:

The member or patient goes to the lab, gets their blood drawn, and that's the center screen. And then the lab sends a result to the doctor, and the doc looks at it, looks at the TSH, yeah, that's normal. Well, then the lab wants to get paid. So then they send a claim over to the health plan. Then the health plan starts the adjudication process, and then in the midst of adjudication sends the information to Avalon, Optum, and under one second we'll apply our rules, evidence-based rules logic, and then take a look at each one of the CPTs or individual lab tests in the profile. And in this case, a TSH and T4, because this person had some criteria, had some symptoms that would be appropriate for testing, would be allowed. But all these other tests...

Dr. Rahul Singal:

Appropriate for testing, would be allowed. But all these other tests, they're not indicated, not allowed, not needed. In fact, some of these other tests that are kind of stuffed into the panel, they're really only indicated in very unique circumstances, such as when somebody may be pregnant and active management for thyroid disease is the only time you really need to do a T3 update. This type of analysis is done post-service, prepayment, and we work with the health plan. So yeah, based upon the criteria, would return a denial. This is one of the examples of how we yield the predictable savings.

Dr. Rahul Singal:

And as we talked about, how do we do it and what's behind all of this, in our routine test management, we have over 70 evidence-based policies. Each one of the policies are between 10 and 30 pages of both coverage criteria and scientific guidelines, as well as industry standard guidance. It covers analytical validity, clinical validity, clinical utility. And then that criteria in the policy is then codified into smart lab rules and triangulates a whole bunch of attributes with if then else type statements, ICD-10s, CPTs, medications potentially if available. And then we go ahead, as we mentioned in the midst of adjudication, web service call to our platform, in under one second return a plus or minus.

Dr. Rahul Singal:

And the last slide gives a snapshot of the routine policies, approximately 70. These policies are updated annually, reviewed by an external academic clinical advisory board. It's a very exciting time in laboratory benefit management. A lot of new tests, not only in genetics that you've heard about from John and you'll hear about as well from Tanya, but even on the routine side.

Dr. Rahul Singal:

I think a lot of the molecular diagnostics, the infectious diseases, there's so much activity from laboratories that are able to do more testing, that I often say, "Hey, more is not necessarily better." If I'm going to urgent care and I've got a cold or sore throat and maybe I really just want antibiotics, which I have to say is almost impossible to get these days, you probably just need chicken soup. But what you don't need is a molecular probe for six, eight or 10 respiratory pathogens, some of which are highly unusual at an initial visit. You need that probe for $200, $300, $400, $500. And those are things that we would manage as part of our evidence-based policies.

Dr. Rahul Singal:

All right, Tanya, I'm going to turn it over to you now.

Tanya Hendrickson:

All right, thank you. So, genetic test management, genetic testing really as a whole, it's a really exciting market in terms of science and growth. In fact, it was published, 20% of Americans have taken a genetic test, whether that's a family origin test or health related. Most genetic tests today are not regulated, meaning they go to market without any independent analysis to verify their usefulness in general claims that are being made from the seller.

Tanya Hendrickson:

These tests range from $100 to $10,000 each. A 15 year analysis claimed a third of genetic tests are ordered in error. It's a lot of waste, it's a lot of unnecessary healthcare costs. But most importantly, in respect to the clinician and the patient, all it takes is that one time where you experience a parent, a spouse, a child, yourself, you get the call saying that nodule they biopsied is a cancerous tumor. Genetic testing is needed to begin treatment.

Tanya Hendrickson:

It's really at this moment where a patient finds themself the most vulnerable. You have to trust. Your clinician knows which test is the best test to order, in a sea of tests that look similar, but differ slightly seller to seller, lab to lab, and that their insurance company agrees with the test that was ordered. This is the opportunity together that we have for health plans, clinicians, patients, to achieve a confidence and that peace of mind to know that a test is doing what it claims to do, while reducing unnecessary costs and member quality of life impacts, due to inappropriate treatments from inaccurate lab tests.

Tanya Hendrickson:

Let's see here. Okay. So, why legacy programs and solutions are not enough to address the increasing complexity and demand for genetic testing. First, traditional prior authorization programs are abrasive. Different health plans have different requirements. They change frequently. And it's a challenge for lab providers and health plans to administer.

Tanya Hendrickson:

Most traditional prior auth programs use CPT codes to validate coverage. However, there are a few hundred CPT codes, far less PLA codes and tens of thousands of genetic tests. Many times, CPT codes are not specific enough to make coverage determinations. And because of this, when the claim is submitted with only a CPT code, your legacy prior auth will struggle to address unbundling or other improper payment occurrences that happen on the back end.

Tanya Hendrickson:

Additionally, for health plans with managed Medicare lives, the plan is required to administer the same policies as the MAC and the state of the servicing lab provider on the claim. There are 28 states weighted more to the home states of the genetic labs, where coverage policy for genetic test claims fall within the MolDX program. I'll describe that on the next slide.

Tanya Hendrickson:

Health plans are often left to develop their own representation and parameters with or without prior auths to adhere to MolDX today. Second, traditional prior auth programs do not address test quality. We know that there's variability in test quality from lab to lab and test to test. And most genetic policies, they include language such as covered test, must meet quality standards.

Tanya Hendrickson:

However, the FDA does not review lab developed tests and most health plans are not staffed. They don't have the expertise, processes in place to perform their own test quality reviews. And therefore the health plans, they really don't have a means to enforce test quality.

Tanya Hendrickson:

Which takes us to the third column here. Because most health plans, they don't perform deep quality reviews of specific tests, they contract with the lab for their entire testing portfolio. They negotiate fees based on CPT codes. It's usually a fixed rate percentage of bill charges, depending. And that includes for those unlisted codes where we know there are over 40,000 tests mapped to just 81479.

Tanya Hendrickson:

So, let's get into how Optum and Avalon and our partners and experts across the industry are really helping to shape up our strategy. I'll start with Optum's exclusive partnership with Palmetto GBA. Palmetto is one of the nation's largest claim administrators to the federal government and other commercial customers.

Tanya Hendrickson:

About 11 years ago, Palmetto established the MolDX program for Medicare fee for service to address the explosion in genetic tests, and importantly, establish a standard to identify genetic tests and assess their validity for CMS. Since Medicare fee for service doesn't really have a prior auth, the program has really enabled Palmetto to set quality standards and enforce them in a post-service automated claim review process.

Tanya Hendrickson:

The Palmetto program is led by MDs and geneticists, and I'm going to explain really two key functions of this program. First is the DEX registry. The DEX registry is the leading genetic test registry across the nation. It's a vital part of the MolDX program. This is where a lab provider will go and register their genetic test.

Tanya Hendrickson:

The output is a DEX Z-Code. That's not a diagnosis Z code, but it's a unique genetic identifier. It's a one-to-one match between the specific test, the lab, MPI and location. There are other genetic registries like NIH's GTR, but just important to note, GTR is not managed and NIH does not verify information that is submitted by test providers.

Tanya Hendrickson:

The second key part of the program is the technical assessment. This is where test providers submit various analytical validity in other clinical evidence that supports the usefulness of their test. MolDX reviews this information, and upon vetting the test specifics, they specify coverage for CMS and they price the test.

Tanya Hendrickson:

Palmetto has been doing this for the last 10 years. So, said another way, MolDX including DEX Z-Code has been required for genetic testing payment in 28 states for Medicare fee for service for at least 10 years. Last year, Optum and Palmetto established an exclusive partnership to license DEX Z-Codes in all the code to code pairings in data.

Tanya Hendrickson:

So, together we are planning to expand technical assessments beyond Medicare covered tests, with technical assessments and processes for prenatal and other [inaudible 00:26:31] tests, as an example. This relationship and independent quality review is a really important part of our genetic strategy. And coupled with the Optum, Avalon partnership, there really isn't anything quite like it in the market.

Tanya Hendrickson:

As I describe a bit of the how, it's important to reinforce the four primary pillars of our strategy. First, invest in industry standards to enforce test quality. Second, enable health plans' total control of defensible evidence-based policies. Three or third, driving affordability. And fourth is continuing to ensure we're improving member and lab experiences.

Tanya Hendrickson:

First, a framework to evaluate test quality. We spoke about this just on the slide prior. Our goal is to enable health plans a means to enforce policy coverage with base quality or vetted tests. This improves clinical outcomes and overall member experiences.

Tanya Hendrickson:

Second, a highly automated NCQA UM-

Tanya Hendrickson:

- estimated NCQA UM service. Identifying discrete lab tests with a DEX Z-Code improves auto approvals with fewer appeals across a broad range of genetic codes, not just a small subset. Third, reduction in prior authorization. Our base configuration for managed Medicare, which is genetic testing compliant, fully automated without prior authorization requirements. We are offering flexible configurations to remove reduced prior authorization requirements for commercial [inaudible 00:28:49] on certain tests.

Tanya Hendrickson:

Next, it would be automated prepayment tools. That includes an auto claim analyzer and other kind of proactive fraud or improper billing practices, just the tools to catch these. Reduce risk with defensible content and independent clinical advisory board of experts in their fields who develop content for our program, including total control to the health plan to adopt the content. And finally, minimizing abrasion. This is consistent, predictable processes for labs with education, outreach and peer to peer as needed.

Tanya Hendrickson:

So let's walk through this example. This is how policies are created and enforced today. First, an independent advisory team establishes guidelines rooted in science. Next clinical utility is established across patient populations. Then procedure diagnosis matching for automation opportunities during prior authorization. Due to the number of unlisted codes or codes with many unique tests that may be associated to them, without knowing the specific test during prior authorization, the outcome is either a clinical review or perhaps an auto approval. With the addition of DEX Z-Codes, that really enables our strategy to offer first, an increase rather, in prior authorization auto approvals. And second, it really gives us the opportunity to offer flexible configurations. Like I've mentioned, our base configuration for MA is totally automated, requires no PA, and so that gives us the opportunity for flexible strategies.

Tanya Hendrickson:

Next we're going to get into some use cases of really how we would do this today and how this works. So first, if we take a look at what would happen today, if you went to the prior authorization screen and you requested a prior authorization for an 84179, it's a nonspecific molecular pathology code. It's widely used for many different genetic tests. We would need to manually review these cases. There are hundreds of different tests that can be represented by this single code. With the addition of the DEX Z-Code, which by the way, ZB6NT is [inaudible 00:32:20] stat panel for BRCA one and two, and it has a CPT code 81479, and it assigned the Z-Code ZB6NT and with the addition of just that DEX Z-Code, with that the Z-Code to diagnosis match to any of the following cancers we can auto approve.

Tanya Hendrickson:

Additionally, it's not on the slide, with the Z-Code diagnoses of breast cancer as well, C50, we can also auto approve for males under the age of 46, for example. So there's a lot of opportunity to really start to automate and innovate here.

Tanya Hendrickson:

There was also recently a report by the Justice Department, it came out in July of this year. The Department of Justice announced criminal charges against about 36 defendants in 13 federal districts across the US. That's more than 1.2 billion in alleged fraud, fraudulent telemedicine, cardiovascular and cancer genetic testing and DMEOPS schemes. So what was the finding? Finding was that millions of dollars of fraud against CMS for unnecessary genetic testing on Medicare beneficiaries that impacted genetic testing schemes where in states that do not participate largely in the MolDX program. So what is the solution really to have maybe prevented some of this fraud? It would be to leverage DEX Z-Codes in prior authorizations. It would be to require providers obtain a DEX Z-Code and submit the DEX Z-Code on a claim for reimbursement. So if the health plan had the tools to be able to match, what was authorized, to what was submitted for payments, then that would be incredibly helpful.

Tanya Hendrickson:

There was another use case that we had reviewed and the background on this one is we analyzed one year of commercial claims data from a large national health plan to identify billing discrepancies from a single lab on a submitted claim versus what was authorized. Finding here was that the health plan required a prior authorization for an unspecific CPT code. The lab received an approval based on the criteria that they had submitted. The lab performed a different test than what was authorized. The lab billed based on the more expensive test that was performed rather than the one that was ordered. So findings here were the test that was billed was 10 times the cost over the authorized test. And that resulted in $1 PMPY in overbilling just from one provider.

Tanya Hendrickson:

So finally, differentiated value. While our goals are ambitious, we believe the industry needs a comprehensive solution more than ever. We believe there are many terrific advances being made in genetic testing and solutions to address genetic testing administration and management and spend. They cannot further burden labs but help promote consistency, predictability and processes across health plans. We believe labs creating high quality tests and following industry standards should be transparent, rewarded to those ordering physicians. We believe in investing in test quality improves clinical outcomes and member quality of life impacts, including out of pocket costs.

Tanya Hendrickson:

Savings can be achieved by enabling health plans with a means to cover good quality tests and tools to prevent fraud and other improper billing practices. And like I said before, transparency really to those physicians so they feel really confident that they are ordering high quality tests from in network providers. So John, I'll turn it over to you to close us up before Q&A.

John Hoffman:

Yeah, thanks so much, Tanya. Just to kind of sum us up and reiterate what differentiates our collaboration with Avalon and Palmetto out in the market. So as we've heard throughout the presentation, we're really excited about the comprehensive multi-pronged approach that we're taking. We really feel like we put together the best of Optum, the best of Avalon, the best of Palmetto to really tackle lab spend and complexity across the market. So really excited about our combined solution, the clinical policy development grounded in science, the automated enforcement of these policies through our tools. The integration with Palmetto's assessment process and codification system ultimately is driving down lab spend, increasing transparency across what tests are the best and ultimately improving outcomes for our members.

John Hoffman:

So that kind of wraps up our formal kind of remarks for the day and we'll pivot now towards Q&A. And I'm actually seeing some Q&A already come into the chat function. We've got a fair amount of time here. I see four or five questions already in the chat function. I'll sort of read off and we'll answer, but we certainly have time. So we encourage you all to submit any questions you have through our chat function. So let me start here. So a couple good ones coming in. How would an ordering physician know that a thyroid panel included excessive tests?

Dr. Rahul Singal:

I can take that one, John, so that's an excellent question. So if they're ordering that thyroid panel for the first time from that laboratory, it's not going to be readily apparent which exact test would be performed until after the lab results come in 24/48 hours later. And I think physicians are quite accustomed to ordering panels, complete blood count as a panel, a chemistry panel, even though you're just looking for a potassium. Historically, it's a lot cheaper to order the chemistry panel if it's automated. And so thyroid panels, however, and other types of panels, they're not necessarily more efficient or cheaper and you may not know.

Dr. Rahul Singal:

And so more and more physicians have been alerted to this. I think there are more and more guidelines out there. So physicians are writing in a TSH directly under the miscellaneous part of the lab requisition form as opposed to checking the boxes on panels. So I forgot to mention, on the routine testing that's all automated. There's no prior [inaudible 00:40:44] on the routine testing. It's fixed criteria, it's all post service, prepayment, whereas a lot historically on the genetic side was more prior law and there's panels there as well. But I think we've got a multi-prong solution. I see a couple other questions related to it, but that was a good question.

John Hoffman:

Thanks, Rahul. Let's keep going here. So what about labs who are not in a MolDX state?

Tanya Hendrickson:

Okay, I can take this. So for a health plan who wants to participate in our solution, we would recommend they should enforce DEX Z-Codes, including to their PAR providers who might be located in a non MolDX state. There are a couple regional, there's a national health plan who does this today.

John Hoffman:

Got it. And are DEX Z-Codes required?

John Hoffman:

... is required.

Tanya Hendrickson:

So to benefit fully from our program, we would recommend health plans and force the leading industry standard for genetic test identification.

John Hoffman:

Thanks Tanya. And good question here, do members get balanced bills?

Dr. Rahul Singal:

I can handle that question. So in the case of both routine testing where it's post service prepayment, if the laboratory services are performed in network, then there's no balance billing, just that, hey, that lab test was not part of the members' benefit. And so there would not be any balance bill or liability from the member side. On genetic testing, there's a prior auth process and so on prior auth similarly, hey, prior auth is not approved. The balance and the test were performed anyways. Again, in network, the member would not be balanced billed.

John Hoffman:

Thanks, Earl. There's another question coming in around approximate savings and corresponding costs for the program, specifically for a $2 million life plan and estimated ROI. I will say we've got multiple sort of pricing models, if you will, with respect to PMPs or shared savings or even kind of full risk type models. So it really depends I would say. With respect to savings, happy to communicate offline over email, by phone, around kind of expected savings by line of business by product to help understand the ROI calculation. And then we even have a couple press releases out in the market from actual client experiences, savings that they've seen through the program. So happy to send more details on that over email afterwards, but depends on the situation. All right. Looking down at more questions.

Dr. Rahul Singal:

I see one on education... I can handle the provider education as Tanya mentioned, and early in the presentation as well. It's a big core component of the value of this lab benefit management program, both in routine testing and in genetic testing and in routine testing for many years now.there's been guidance by a lot of the professional societies about ordering the right tests and following the evidence and not over-ordering tests that are not clinically indicated. And so whether it's choosing wisely in other programs by the Academy of Family Practice and American Port of Internal Medicine and the AMA.

Dr. Rahul Singal:

And so within our policies, all of the lab policies, the health plans publish the policies and readily available to both physicians and laboratory providers. And then furthermore, on the genetic testing side, during the prior auth process, our team does a fair amount of peer to peer education directly with the ordering physician. And we get a lot of positive feedback from that and we're trying to get the most appropriate test for the member at that time. And so oftentimes it's not that the patient doesn't need a genetic test, it's perhaps not the one ordered and there might be a better one that would be more suitable. And so some of that is done, and again, a lot of positive feedback from ordering physicians.

John Hoffman:

Yeah. And we're getting a question around our relationship with CMS. Just to clarify, we have a relationship with Palmetto GBA, which is a regional MAC that processes claims for fee for service Medicare. We don't have a relationship in this program through CMS directly. Want to clarify that.

John Hoffman:

Okay. Tanya, Earl. I'm looking at some more questions coming in. Any-

Dr. Rahul Singal:

Yeah, I think it was a good question on the auto approval process for genetic testing. So specifically around the example with the Z code, with the unique BRCA test that was represented in the Z code. For those of you in the genetics business, BRCA will have their own distinct set of CCPT codes. But this one, the one that we gave the example was a unique test. And so today, it's done as a miscellaneous 881479. And so on those types of tests where it's an auto approval as part of prior auth, hey, if it's on a predetermined ICD 10 list, that would be in the policy and it's part of the PA portal submission. You put in the CPT, the 81479 in this case and the Z code and the ICD 10 and then some of the member demographics. If it's one of those appropriate conditions, you'll get an instant approval.

Dr. Rahul Singal:

If it's not, you're not going to get a denial, it's then going to go to manual review. That's part of the auto approval as part of a prior auth process. And so there's separate criteria in a post-service setting, especially for Medicare, where we're leveraging the Palmetto experience of 10 years of Medicare fee for service. And that's done completely without prior auth for those labs that are in one of the 28 mold X states. And then hence would send no prior auth, send a claim. And based upon criteria that Medicare uses for Medicare patients, we would render the appropriate approval or denial. A lot of detail in that answer. And I think that's something offline be happy to discuss more and entertain.

John Hoffman:

We've actually got... There's a lot of questions.

Tanya Hendrickson:

Yeah, there's one other question. There's one question on what a platinum test list is. I think in terms of that, that's a future phase of our strategy and test quality, said it so many times now. It's a pillar in our strategy for certain and establishing base test quality through technical assessments and sort of piggybacking on what the Moldex program is already successfully doing for CMS is phase one. And obviously expanding that to test that wouldn't be covered by Medicare, like prenatal and incorporating that. That's our base quality check and it is a detailed technical assessment process that the team at Palmetto works really hard at and does a good job doing.

Tanya Hendrickson:

By folding that into our strategy, what we're really doing is we are enabling health plans, a means to ensure that they are covering tests, quality tests. Then in the future, what we would like to begin to do is really get to a deeper level of quality or evidence assessments. Again, partnering with experts who can do this with us and to be able to really identify best of breed tests in specific areas. And that's sort of our future vision and we're still kind of unpacking that.

John Hoffman:

Yeah, I see a question on the location of the labs. What does our program cover? So it's outpatient coverage, so obviously independent labs, labs done at doctor offices, labs done at outpatient hospital facilities. It excludes emergency room, emergency department settings, as well as hospital inpatient.

Tanya Hendrickson:

I can read a question here. It says, "Does every Z code get a technical assessment? What happens if they don't have a technical assessment? Are they outside the scope of the program?" This is a great question and I want to sort of answer this again just to make sure that maybe what I'm saying is clear. So you're right, not every test today has a technical assessment.

Tanya Hendrickson:

Palmetto runs the Moldex program on behalf of CMS for Medicare fee for service. So today the technical assessments that they have really focused on building have been centered around those tests that they would need to assess for the purposes of Medicare coverage. So through our partnership with them, this is something that we're working on with them where they are the experts here and they are building out technical assessments on other types of tests that we feel are really important and covered a broad sort of impact or availability across the types of genetic tests that we see and that the health plans who work with us, it's important to them as well. So we are continuing, that's part of that evolution and it's part of what we as a product team are building out with our partners.

John Hoffman:

Thanks Tanya. There are a series of questions still coming in at this point. We're going to have to probably table those for offline conversations. We appreciate all the engagement today. I've actually flashed up on the screen a contact here at Optum. If you have any additional questions, we can sort of flow all those through this contact. We're happy to have, again, more offline conversations, talk to you more about the programs, talk to you more about expected savings, ROI, et cetera. If you can, flow all that through Michelle. She's in our marketing group and at this point we appreciate the time. And Joanne, we'll kind of turn it back over to you to wrap us up here.

Joanne:

Thank you so much. And to our speakers, thank you for that great presentation and for sharing your thoughts today. And thank you to the audience for participating in today's webinar. This concludes today's presentation. Thank you again and enjoy the rest of your day.