What You Should Know:
– Availity®, the nation’s leading real-time health information network, and Concert®, the leading provider of clinical content and payment accuracy solutions for advanced diagnostics, have partnered to digitize and automate the prior authorization and payment processes for genetic tests.
– Together the companies will enable more consistent, transparent, and instantaneous prior authorizations, reducing administrative burden in the delivery of precision medicine.
Availity and Concert Collaborate to Streamline Genetic Testing Authorizations and Billing
Availity is transforming healthcare experiences by facilitating seamless exchanges of clinical, administrative, and financial information within established workflows. As the largest real-time health information network in the U.S., Availity connects over 95% of payers, 3 million providers, and 2,000 trading partners. Through its robust, cloud-first technology platform, Availity drives efficiency, security, and innovation using AI, data-driven insights, and a diversified product portfolio, establishing itself as a leader in the future of healthcare interoperability.
Addressing the Challenges of Genetic Testing
Advancements in genetic diagnostics and therapies allow for more personalized patient care, yet the complexity and cost of administering genetic tests remain a significant challenge. These tests often require prior authorization, which can overwhelm Utilization Management (UM) teams with rapidly evolving clinical guidelines, state-level biomarker regulations, and complex billing codes—especially for prenatal, oncology, and pharmacogenetic tests. The intricacy of these claims often leads to delays, denials, and manual reviews, causing confusion and frustration for patients, providers, and health plans.
Transforming Authorization with Concert and Availity Integration
To tackle these issues, Availity is integrating Concert’s clinical criteria, coding standards, and the Concert GTU® test identifier into its End-to-End Authorization solution. This collaboration will automate prior authorization processes, replacing manual, error-prone workflows with seamless, real-time authorization recommendations within existing health plan and provider systems. The expected benefits include:
• For Providers: Greater consistency and transparency in authorizations, with many rendered instantly.
• For Health Plans: A streamlined prior authorization process, clear knowledge of services rendered, and reduced burden on medical directors for complex reviews.
• For Patients: Reduced delays and uncertainty when genetic tests are ordered, with fewer surprise bills following testing.
A Vision for Instant Reimbursement
Rob Metcalf, CEO of Concert, shared, “At Concert, we envision a day when laboratory test reimbursement is determined instantly at the point of patient care. Concert’s flexible data platform integrates seamlessly with Availity’s network, enabling efficient, evidence-based precision health.”
This partnership marks a significant step toward improving the efficiency and accuracy of genetic testing authorizations, offering more consistent and timely healthcare experiences for all parties involved.
