If you need a mastermind to join your finance team, please reach out. It’s a mouth full. But if the price was $297 (like Beaumont), I would only pay that. Almost. There are a couple of different versions of this test, but I was interested in the CPT code represented by 81206. My insurance company will likely always be nameless for the blog.*. Clinical testing for most genetic variants is performed in a CLIA-certified molecular genetics or molecular pathology laboratory using technologies such as allele-specific polymerase chain reaction (PCR), Sanger dideoxy sequencing, pyrosequencing, multiplex ligation-dependent probe amplification (MLPA), or mass spectrometry (MS). 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. That’s what we all want to pay for anyway. But then again, other than Max, who is really pricing out this type of test? Max can get pretty micro when talking about healthcare economics and how pricing is currently set up. They provide a description and the CPT code and it makes everything much easier to understand. One of the cool things about running Max Out of Pocket is I get to look at both the macro and micro aspects of healthcare. Much better than my regurgitated CPT definition. 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. We have reviewed some “simple lab tests” like lipid panels and basic metabolic panels in the past. Always seek out a professional for financial advice and a trained healthcare provider for healthcare advice. Reference lab pricing would likely come in between $375 and $600 for most of these places. I would consider anything over $1,000 on the upper end of the pricing spectrum for this CPT code. 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 except for government payers, there is technically nothing mandating a price cap for this service for commercial carriers or uninsured patients. Interesting post and perhaps I can offer a little insight. There is also a difference in sensitivity between the qualitative (is it there) and quantitative (how many copies are there) PCR. 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. This is actually closer to where I would expect to see the price for this service in my anecdotal but valid experience. Unfortunately, it has also become an easy target for media outlets like Bill Of The Month, that likely don’t fully understand the bigger picture. Welcome to PathWest’s Diagnostic Genomics Laboratory. This pricing seems quite reasonable from my experience, as further noted below. Again, complicated stuff and I am not an expert. If we have an oncologist reading this, feel free to break this down into layman’s terms for people like me. Another problem is most hospitals (particularly the larger systems) didn’t embrace this charge posting requirement; they ran from it. I also happen to know my own personal insurance company has negotiated this test down to a maximum charge of about $1,200 at a few of my local hospitals. They used this sample to determine their pricing effective 1/1/2018. The fusion gene can result in a couple of different forms of the active enzyme (likely why there are different versions of the test.) Max is on the industry’s side here. They have a world-renowned oncology program that some people probably are willing to travel to. This is all following the ‘Protecting Access To Medicare Act of 2014’ that was signed into law back in April 2014. My understanding is the BCR gene has three different regions referred to as “major”, “minor”, and “other points”. You can’t put a price on remission. Always consult with a certified professional before making any financial decisions. But in healthcare, for me, it’s almost easier to understand the granular level micro examples than the macroeconomic issues. Here are a couple of options from Stanford Health Care. I also don’t want one of the big insurance companies coming after me, my blog, or my family. ‘Protecting Access To Medicare Act of 2014’. Almost. 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. Unfortunately, the system currently is set up with various price points on the way to remission. Tags: 81206BCR/ABL1CHARGEMASTERchronic myelogenous leukemiaCMLPCR. Genetic testing typically is covered by health insurance when recommended by the patient's doctor. In the meantime, some commercially insured cancer patients are caught in the middle cross-subsidizing the system with their overpriced high deductible health plans. But we are years out from having meaningful transparency on that process. Throw in a strong bonus incentive for positive clinical outcomes. We are not financial or healthcare professionals and have no formal training. Max happens to know that is far from the case. It is basically looking for a mutation of the BCR/ABL1 gene often found in patients diagnosed with chronic myelogenous leukemia (CML). How Much Should Molecular Genetic Testing Cost? All Rights Reserved. For the tests that are covered by Medicare, the rebate provided is often less than the cost to us of providing the test. I also run into random characters from across the internet occasionally who actually have to deal with the system as a patient. Price strategy committees are popping up. So, in my relatively short career, even I have seen some pretty wild swings for this particular lab test. Then there is always the “reference” lab route. Molecular diagnostics is the outcome of the fruitful interplay among laboratory medicine, genomics knowledge, and technology in the field of molecular genetics, especially with significant discoveries in the field of molecular genomic technologies. How much you can expect to pay out of pocket for genetic testing, including what people paid in 2020. We can pretty easily see that Medicare pays $163.96 for this particular form of molecular genetic testing. I refuse to put a price on cancer remission. In theory, the retail pricing for this test would be set by the “competitive” commercial insurance market. CPT code 81206 represents this particular test. The truth is, as a so-called expert, I have no idea how much this test should cost. 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. Molecular testing is capable of detecting active COVID-19 infections in the human body. *I don’t blame my insurance or any other specific insurance company for the current system. Therefore, there are two other versions of this test for the other regions and those are represented by code 81207 (minor breakpoint) and 81208 (other breakpoint). 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.

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