Feel free to skip the next paragraph if you can’t handle a few technical terms. Max Out of Pocket © 2020. I am on a high deductible plan, so that would initially all come out of my pocket until I hit my $6,600 max out-of-pocket. Unlike most hospitals, they share the CPT codes. Another problem is most hospitals (particularly the larger systems) didn’t embrace this charge posting requirement; they ran from it. I highlighted the two that probably meet the definition of this test. Additionally, the Medicare fee schedule doesn’t impose out-of-pocket costs to the Medicare beneficiary for services paid off this fee schedule, even if they haven’t met the Medicare Part B Deductible. How much you can expect to pay out of pocket for genetic testing, including what people paid in 2020. In the meantime, some commercially insured cancer patients are caught in the middle cross-subsidizing the system with their overpriced high deductible health plans. CPT code 81206 represents this particular test. If the price is truly a function a cost here and we are practicing “itemized healthcare”, I would question the difference. We even looked at my own elevated lipid panel and how I got it for free. Then there is always the “reference” lab route. Medicare has a nice easy to read fee schedule that we can easily drill down into here. Hopefully, this explanation is not too dense. The test we are going to talk about today is pretty amazing. Here is a look that the Q2 2020 Medicare lab fee schedule. ‘Protecting Access To Medicare Act of 2014’. Side note: Beaumont is an excellent health system and has treated many members of my family when I lived in Michigan. It’s priceless. Again, a small assumption on this since they don’t share the CPT code. How Much Should Molecular Genetic Testing Cost? CML is a clonal blood malignancy that begins in one of the blood stem cell lines. The fusion gene can result in a couple of different forms of the active enzyme (likely why there are different versions of the test.) For the tests that are covered by Medicare, the rebate provided is often less than the cost to us of providing the test. The big problem is most of them did not include the CPT code on their listing which is one of the easier ways to communicate complex medical terminology. I am glad you also clarified on the “qualitative” vs. “quantitative” as my wife if an AP statistics teacher and was questioning how that was being used in this context. So I naively started thinking market pressure might help us with (but not fix) some of the inflated pricing around the country. My understanding is it involves chromosome 22 and chromosome 9. They included the bare bones minimum and it was often buried deep in the website. I have nothing but good things to say about your organization. With more price transparency pressure coming from Medicare in 2021, I think some hospitals are probably moving into setting their itemized price as a function of cost and competition. I’ve never been a fan of the opaque negotiation and admit I like the transparency of Medicare fee schedule. Price would be the last thing on my mind. Unfortunately, it can be hard to pin the cost down on some of these more complicated tests depending on the setting and overhead that runs through a laboratory. I am sure it would be difficult to price out an 8+ year treatment plan, but I am sure there are smart clinicians and actuaries out there who could figure something out. Frankly, I work in the industry and I really don’t have a basis for pricing this molecular genetic test outside of the data the Medicare program has developed. I also run into random characters from across the internet occasionally who actually have to deal with the system as a patient. With just one lab test, I am going to demonstrate how complicated healthcare reimbursement has become. Try looking at the whole system. What I find interesting about these prices is as of 1/1/2018, most of them are derived from the weighted median private insurance payer rates. So, the test can be used in diagnosis and monitoring. In fact, I have hit three or four of them and I am exhausted. It’s a mouth full. In other words, it is not as easy as pulling up CPT code 81206 on the hospital’s website and writing down the price. We can make some educated guesses based on the description, but without the CPT code, we can’t be 100% sure there is a one-for-one match. It’s priceless. I refuse to put a price on cancer remission. In other words, Medicare is peeking in at what everyone else is paying and making their price the average of that. Evidently, their charge may differ depending on if it is a “qualitative” test vs. “quantitative” test even though the CPT code can be used universally. I am very happy there are people out there much smarter than Max who have figured all this out. In this case, we know we are on the same page. Especially, when those examples impact people we know. To be clear, I am not necessarily calling Stanford out here. Quest Diagnostics offers genetics, molecular and prenatal testing, tests for disorders, mutations and antiplatelet therapy, CYP2C19. Max can get pretty micro when talking about healthcare economics and how pricing is currently set up. As we learned during our review of the lipid panel, Medicare sets the pricing for facilities that accept them as a payer and meet the conditions of participation. I have absolutely no idea how that would work for chronic myelogenous leukemia. Since the chargemaster is just a starting point for negotiation, the stronger negotiator (hospital or insurer) can drive up or down the reimbursement level. Please indicate on the referral if this is not required. I would consider anything over $1,000 on the upper end of the pricing spectrum for this CPT code. I might take a quick look at my annual max out-of-pocket, but that’s about it. Your PCR test- CPT 81206 can look at this molecular response. We have reviewed some “simple lab tests” like lipid panels and basic metabolic panels in the past. My understanding is a patient getting treated for CML might need to have this test several times per year to help monitor the tyrosine kinase inhibitor treatment/therapy for CML. But we are years out from having meaningful transparency on that process. But how much should it cost? The blame game is just too complicated and I still don’t believe there is necessarily intent here. For patients not covered by health insurance, genetic testing cost ranges from less than $300-$3,000 or more, depending on the individual, the type of test and the comprehensiveness of the test. Almost. Again, complicated stuff and I am not an expert. Here are a couple of options from Stanford Health Care. Molecular Genetics Test and Price List Massively Parallel Sequencing ... consent for genetic testing from the patient/ parent/ guardian must be obtained prior to testing and a copy ... ($2,500 total cost). My understanding is the BCR gene has three different regions referred to as “major”, “minor”, and “other points”. It can check for the presence of the mutant cancer gene at very low levels. The cost increases if more than one test is necessary or if multiple family members must be tested to obtain a meaningful result. They used this sample to determine their pricing effective 1/1/2018. "Genetic testing is cost-effective as it allows clinicians to prescribe chemotherapy in a tumor-specific manner. Medicare started sampling these private insurance prices in 2017. Lastly, some hospitals like Johnson Memorial Hospital go above and beyond. Here are the two options from Beaumont Hospital System’s chargemaster in Michigan for this particular service. The gap between what my insurance and Medicare are each willing to pay for this service is over $1,000. Unique genetic markers of the virus can be found in RNA that only remains in the body while the virus invades and replicates itself. There are a few other moving parts to it but that’s the gist of it. The “consumer-friendly” description of this is a translocation analysis (BCR/ABL1) major breakpoint. If we have an oncologist reading this, feel free to break this down into layman’s terms for people like me. Notify me of follow-up comments by email. I’ve mentioned this before here on the blog. The not-so consumer-friendly description uses CPT code 81206 for the identification of major breakpoint, occurring at p210 in a 5.8 kb major breakpoint cluster region (M-bcr) around exon b3. The test we are going to talk about today is pretty amazing. They have a world-renowned oncology program that some people probably are willing to travel to. We are talking some pretty scientific stuff here.
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