Independent Medical Reviews
June 16, 2016
Genetic testing is prevalent in modern medicine. It gives physicians definite information about the patient, often supporting a diagnosis or influencing a treatment plan. Common types of genetic tests are prenatal testing and newborn screening for specific diseases or syndromes, predictive and carrier testing such as for the “breast cancer gene” BRCA, or diagnostic testing.
While genetic testing can be beneficial, it is not always necessary or the right course of action. Physicians – and a patient’s insurer – must determine whether the test is a medical necessity or whether it is merely for an investigational purpose.
An insurer approves or denies coverage of genetic testing based on the patient’s policy language. Policies often cover genetic testing when it is medically necessary according to evidence-based treatment guidelines or when the patient is deemed high risk for a disease. For example, an insurer may cover the test for the BRCA gene if the patient has an extensive family history of breast cancer.
If the insurer denies coverage, the patient then has the option for an independent medical review (IMR).
IMRs are made by independent and practicing physicians. These are experienced professionals who understand the weight of their decisions. Patients can be sure that these doctors take their inquiries seriously.
IMRs prevent insurance companies from making medical decisions for patients. The determination of whether a patient would benefit from a specific test or treatment begins with a physician, and IMRs ensure those decisions are either supported or refuted by another qualified physician. Patients can be confident that it is not an insurance company administrator who does not have the proper education or training making their medical decisions.
The independent physicians review evidence related to the testing including patient history, current symptoms, diagnostics performed, and other circumstances. They then provide an objective written opinion on whether the genetic testing was medically necessary, appropriate based on medical best practices and policy guidelines, as well as whether the test was a cost effective means of determining the information the doctor sought.
“Advanced Medical Reviews is proud to have one of the industry’s largest independent physician review panel, ensuring we provide every patient with the expertise they need and deserve,” said AMR’s VP of Operations Kelly Ritchey-Davoren. “Our propriety database and workflow technology gives physicians the information they need at their fingertips and allows them to review decisions thoroughly but efficiently, complying with all federal and state workflow and timeline regulations.”
In the past, there may not have been a clear administrative road to appeal a denial of insurance coverage. Or if the road existed, it may not have been well explained to patients. IMRs allow for patients to disagree with an insurer’s decision and obtain a second, objective opinion without resorting to attorneys or giving up in confusion.
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