NEW YORK — The denials UT Southwestern Medical Center's cancer center was receiving from one insurance company when it began billing for genetic counseling services didn't make sense: The genetic counselors were billing for their services using a CPT code issued specifically for them, but the payor still denied the claims, stating there was a mismatch between the code billed and the provider listed.
This set off a yearslong quest for Sara Pirzadeh-Miller, associate director of the cancer genetics program at UT Southwestern Simmons Comprehensive Cancer Center, and her colleagues to overturn these denials and establish more reliable reimbursement for genetic counseling services at the institution.
While not all genetic counselors bill for their services, many do. According to the 2024 Professional Status Survey conducted by the National Society of Genetic Counselors, 63 percent of responding genetic counselors bill for their services, a portion that has remained fairly constant in the society's yearly surveys. When genetic counselors do bill for their services, a 2017 analysis of one institution in the Journal of Genetic Counseling found that slightly more than half, nearly 53 percent, of those encounters billed to commercial insurers were partially or fully reimbursed. A similar study in the same journal from 2021 of a separate institution's experience found 65 percent of genetic counseling encounters billed to commercial insurance were covered.
Still, billing and reimbursement remain key issues for the profession as it aims to demonstrate its sustainability in the larger healthcare ecosystem. "That's really critical for showing the hospital, showing the institution, that you contribute to the bottom line," said Pirzadeh-Miller, who is also the president-elect of NSGC, which for years has been trying to tackle the multifaceted reimbursement challenges the profession has historically faced.
Among the biggest hurdles is that the US Centers for Medicare & Medicaid Services doesn't recognize genetic counselors as providers, but on the commercial payor side, consistent and sustainable reimbursement has also been a persistent challenge. Given the payment difficulties, a lot of institutions don't bother billing for genetic counseling services.
In fact, UT Southwestern's cancer center did not bill for genetic counseling services until 2019, Pirzadeh-Miller said. The NSGC survey found that among the genetic counselors who do not bill, 45 percent said they did not because their institution decided against it. Some institutions might have the resources to offer genetic counseling and consider it an overhead expense, but genetic counselors' inability to bring in revenue from reliable reimbursement likely factors into smaller institutions' decisions to hire them.
Pirzadeh-Miller's institution decided to try to recover at least some of the genetic counseling expenses as the group grew. After the cancer center implemented the billing change — and warned patients they might be billed — she and her colleagues in the billing and finance offices also instituted a monthly review of charges and reimbursement denials to see whether they were getting paid. A careful review of the data with the financial team revealed that much of the coverage denials were from Blue Cross Blue Shield of Texas, which administers UT Select, the employee insurance plan. "We had our own patients who are employees in the [UT] system saying, 'Hey, I got denied. I work here, and I can't get [genetic counseling] covered?'" Pirzadeh-Miller recalled.
When Pirzadeh-Miller and her colleagues delved into the denials from BCBSTX, they discovered the payor was refusing to pay these claims because it erroneously concluded there was a mismatch between the genetic counseling billing code used and the provider type — genetic counselor — listed.
UT Southwestern genetic counselors were billing the CPT code 96040, which is specifically for genetic counselors. Under this code, which will be retired at the end of the year for an updated one, trained nonphysician genetic counselors can bill for 16 minutes to 30 minutes of face-to-face services such as evaluating patients' and their families' disease history and providing support.
Further, genetic counseling was a covered benefit under the UT health plan.
As such, Pirzadeh-Miller and her team argued that BCBSTX's denials were in direct contradiction with the genetic counselors' CPT code and the plan policy. "We laid this argument out, [and] we finally, after months, got a return email to basically say in writing: 'You're right,'" she said. "What we were saying is: 'You're not honoring your coverage policy, if you don't recognize the provider that provides a service. You're denying something that you should be covering.'"
The lack of recognition for genetic counselors as a provider type within BCBSTX's system was particularly frustrating, Pirzadeh-Miller noted, since the payor had already "credentialed" genetic counselors at UT Southwestern's cancer center, meaning that the payor had reviewed their qualifications and accepted them as providers who can provide genetic counseling services in-network.
Commercial payor credentialing is one of many steps, alongside institutional credentialing, potentially state licensure, and receiving a national provider identification number, that NSGC highlights as important for billing and reimbursement. But genetic counselors can run into challenges with these steps, as well. Elena Ashkinadze, a genetic counselor in New Jersey, for instance, has been unable to become credentialed by a payor in that state. That payor told her it does not credential genetic counselors.
In this case, the UT Southwestern group was able to complete the steps it needed for reimbursement. "They did all the right things to where they should have been reimbursed," Jennifer Leonhard, a genetic counselor at Sanford Health and first author of the 2017 Journal of Genetic Counseling analysis, said.
Still, Pirzadeh-Miller said she had to follow up for months and months to get BCBSTX to fix the error in their system so that genetic counselors as a provider type were recognized. That fix came through about a year ago. She and her colleagues are still monitoring changes and reimbursements monthly and have found that BCBSTX is reimbursing them properly.
BCBSTX did not respond to a request for comment about their system not recognizing UT Southwestern's genetic counselors by press time.
"What we did was nothing magical," Pirzadeh-Miller said of her team's handling of this experience with BCBSTX. "We looked at data, we figured out the problem, and we persisted and were tenacious. … I had a two-week reminder on my calendar [to reach out to the insurer] for two years."
Being able to consistently bill commercial payors and get reimbursed for genetic counseling services would enable genetic counselors to gain further recognition and underscore the value of their services within the healthcare system and help the sustainability of the profession.
"If you think about other mid-level healthcare professionals, they bill for services," Pirzadeh-Miller said, referring to professionals like nurse practitioners and physician assistants. "This is aligning with the healthcare system appropriately, and so that's really not out of the expectations for a patient."
Leonhard, who also guest lectures on billing and reimbursement at various genetic counseling training programs, added that while there are policies, literature, and guidelines supporting the value of genetic counseling, healthcare in the US is ultimately a business. Reimbursement, she said, helps show an institution that it is worth budgeting for a genetic counselor and perhaps even for genetic counseling assistants or other support staff. "Cost and reimbursement does factor in how these decisions are made," she said.
Moreover, commercial payors do pay attention to CMS coverage policies. And the fact that CMS doesn't recognize genetic counselors as healthcare providers, hindering their ability to bill for services provided to Medicare patients using the current 96040 CPT code or the code slated to take effect in 2025, has made things difficult for the profession. Leonhard noted that her 2017 analysis of reimbursement for genetic counselors excluded services provided to Medicare or Medicaid patients. Likewise, the 2021 study noted that services for Medicare or Medicaid patients were not reimbursed, though Medicaid managed care plans did sometimes provide reimbursement.
"CMS recognition is not the sole thing that's going to get us billing and reimbursement," Leonhard said. "However, it's a big support to say, CMS is doing it. Many insurances are going to be more understanding once those [coverage] criteria and guidelines are put out there by CMS."
Legislators, spurred by advocacy from NSGC and the broader genetic counseling community, have introduced a number of bills into Congress that would establish CMS recognition for genetic counselors, but none have yet been successful.
The upcoming rollout of the new CPT code for genetic counseling services could present a chance to educate payors about the profession. Pirzadeh-Miller hopes the transition from the original CPT code, 96040, to the new code, 96041, is smooth, but she acknowledged that there are bound to be some hiccups. On the positive side, the friction experienced in implementing the new code is bound to lead to more conversations between institutions, genetic counselors, and payors.
"This is a great opportunity to say [to insurers]: 'Here's who we are. Here's what we do. Here's how we bill appropriately for our services. And here's why it's important that [we're] recognized appropriately and reimbursed to the highest level appropriately,'" she said.