I like the idea of packaging some of this stuff up and paying a “fixed fee” to manage a problem for several months/years. Not too dense at all, this is a perfect explanation. 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. Max is probably out of his league here. I don’t blame individual insurance companies or hospitals for where we are today. In the meantime, some commercially insured cancer patients are caught in the middle cross-subsidizing the system with their overpriced high deductible health plans. There is also a difference in sensitivity between the qualitative (is it there) and quantitative (how many copies are there) PCR. So, the test can be used in diagnosis and monitoring. Your email address will not be published. Almost. In fact, more and more commercial pricing contracts are using a multiplier of Medicare rates as the “starting point” for negotiating reimbursement. The gap between what my insurance and Medicare are each willing to pay for this service is over $1,000. Quest Diagnostics offers genetics, molecular and prenatal testing, tests for disorders, mutations and antiplatelet therapy, CYP2C19. Ah, here is where Max fits in. In fact, I have hit three or four of them and I am exhausted. Max is kind of a ‘market guy’. Please indicate on the referral if this is not required. We recognise that this will not be easy for many patients and families. 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. It’s a mouth full. I also don’t want one of the big insurance companies coming after me, my blog, or my family. So, in my relatively short career, even I have seen some pretty wild swings for this particular lab test. But in healthcare, for me, it’s almost easier to understand the granular level micro examples than the macroeconomic issues. The 50th percentile price would come in around $500 and about $780 for the 75th percentile. The test we are going to talk about today is pretty amazing. That almost always comes in cheaper than the hospital setting. Another problem is most hospitals (particularly the larger systems) didn’t embrace this charge posting requirement; they ran from it. Max is on the industry’s side here. 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. This site and author are NOT responsible for any losses or damages you may incur in your own investing. It is more systemic than that. They may be spreading their cost differently than Beaumont or practicing cost-shifting. The fusion gene can result in a couple of different forms of the active enzyme (likely why there are different versions of the test.) 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). Unfortunately, the system currently is set up with various price points on the way to remission. Always consult with a certified professional before making any financial decisions. Medicare started sampling these private insurance prices in 2017. So I naively started thinking market pressure might help us with (but not fix) some of the inflated pricing around the country. I might take a quick look at my annual max out-of-pocket, but that’s about it. How Much Should Molecular Genetic Testing Cost? My understanding is it involves chromosome 22 and chromosome 9. Genetic testing typically is covered by health insurance when recommended by the patient's doctor. The “consumer-friendly” description of this is a translocation analysis (BCR/ABL1) major breakpoint. Molecular testing is capable of detecting active COVID-19 infections in the human body. CPT code 81206 represents this particular test. At times, all three might be needed. 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). But if the price was $297 (like Beaumont), I would only pay that. Molecular genetic testing is almost as complicated as the pricing for the service itself. We have reviewed some “simple lab tests” like lipid panels and basic metabolic panels in the past. Your PCR test- CPT 81206 can look at this molecular response. It results from a translocation (chromosomes 9 and 22 rearrange with each other creating something called the Philadelphia chromosome). Personally, I don’t think “itemized healthcare” is going to be the model of the future. It’s priceless. We are not financial or healthcare professionals and have no formal training. There are a couple of different versions of this test, but I was interested in the CPT code represented by 81206. So my question is, if the weighted median private insurance payer rate is only $163.96, why are both the retail price (for some hospitals) and contracted price (like mine) often so far above this? Where Do I Keep All Of These Medical Office Buildings? I also run into random characters from across the internet occasionally who actually have to deal with the system as a patient. We provide comprehensive genetic testing services to patients in WA public sector hospitals, patients in the care of private consultants and hospitals, as well as to genetic health practitioners elsewhere in Australia and overseas. It is basically looking for a mutation of the BCR/ABL1 gene often found in patients diagnosed with chronic myelogenous leukemia (CML). 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. Interesting post and perhaps I can offer a little insight. My guess is the reference labs must be weighing down the average. To be clear, I am not necessarily calling Stanford out here. With just one lab test, I am going to demonstrate how complicated healthcare reimbursement has become. The resulting BCR-ABL fusion gene from this translocation creates an enzyme that is not regulated appropriately (active when it shouldn’t be). Required fields are marked *. 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). Then there is always the “reference” lab route. I’ve mentioned this before here on the blog. I also just googled the Philadelphia chromosome and found a few diagrams that helped. I’ve never been a fan of the opaque negotiation and admit I like the transparency of Medicare fee schedule. To be fair, there were some copyright concerns around the industry on whether or not they could publish CPT codes online. Feel free to skip the next paragraph if you can’t handle a few technical terms. You can’t put a price on remission. 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. 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. To be clear, my insurance could allow/pay about 7.3 times what the Medicare beneficiary would pay for this service at my local hospital. Max Out of Pocket © 2020. We are talking some pretty scientific stuff here. Unfortunately, when I type 81206 into their pricing website, I don’t get any hits. Unlike most hospitals, they share the CPT codes. Hopefully, this explanation is not too dense. If I had cancer, I would likely take the path of least resistance to get this test as quickly as possible. The cost increases if more than one test is necessary or if multiple family members must be tested to obtain a meaningful result. Throw in a strong bonus incentive for positive clinical outcomes. So, enzyme inhibitors are the standard treatment for CML, and the response to treatment is followed molecularly by looking at the drop in the BCR-ABL RNA. I’m a so-called expert on this stuff, and even I can’t always pick them out. I highlighted the two that probably meet the definition of this test. I just think it is interesting to note the price difference and it makes them an easy target. In other words, Medicare is peeking in at what everyone else is paying and making their price the average of that. Price strategy committees are popping up. Again, I will leave the clinical difference to the oncologists. Side note: Beaumont is an excellent health system and has treated many members of my family when I lived in Michigan. Especially, when those examples impact people we know. These internet encounters often spark questions about how much something costs. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window). But except for government payers, there is technically nothing mandating a price cap for this service for commercial carriers or uninsured patients. Tags: 81206BCR/ABL1CHARGEMASTERchronic myelogenous leukemiaCMLPCR. We can save $12-$15 on this test if you are willing to drive across town.

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