Discovering the AvalonSelect Genetic Network & Lab Technology Evaluation (LTE) Service

Michele Norton, VP of Product Marketing at Avalon, introduced the webinar on AvalonSelect Genetic Network and Lab Technology Evaluation (LTE) Service. The event featured Mike Snyder, EVP of Network, Michael Lemieux,  Medical Policy Manager, and Sarah Bretz, Senior Product Manager, as panelists.

Mike Snyder highlighted the complexity of genetic testing due to scientific advancements and regulatory changes, such as biomarker legislation. He emphasized Avalon’s holistic approach to managing these complexities by coordinating a suite of services that extend a health plan’s network management capabilities. One of these services, AvalonSelect, can help health plans manage genetic testing more effectively by simplifying test management and reducing costs. The service also seeks to expedite reimbursement processes for preferred labs.

AvalonSelect Services
AvalonSelect’s services aim to enhance existing network management without replacing it. Key services include:

• Lab Network Management: Identifying and partnering with the best labs, ensuring alignment with policy coverage, and managing the entire process.
• Quality Assurance: Ensuring provider accreditation against industry and plan standards, and assessing new testing technologies for clinical and analytical utility.
• Ongoing Collaboration: Regularly reviewing laboratory test utilization and ensuring appropriate member access to necessary tests.
• Future Innovations: Utilizing laboratory tests to guide downstream therapy, particularly in oncology.

AvalonSelect covers a broad range of genetic tests, categorized using AMA procedure codes. The network ensures the right providers conduct appropriate tests, aiming for high-quality and cost-effective outcomes.

Avalon addresses coding complexities by using Mopath codes to replace outdated stacking codes. This helps clarify the specific tests being performed and mitigates potential misuse, ensuring transparency and reducing fraud, waste, and abuse.

AvalonSelect offers extensive support to providers, including:

• Lab Education: Comprehensive onboarding for labs on Avalon’s processes.
• Provider Inquiries and Claims Support: Managing provider queries and claims, including reconsideration management.
• Collaboration with Plan Networks: Working closely with plan network teams to ensure adequacy and compliance.

AvalonSelect’s Gold Carding program aims to reduce prior authorization (PA) requirements for providers. Criteria for Gold Card status include:

• Familiarity with the provider and a track record of PA requests.
• A 90% approval rate for PA requests over the past ten months.
• Provider agreement to ongoing audit checks.

Avalon monitors utilization and performs quarterly audits to ensure compliance, implementing corrective actions if necessary.

Lab Technology Evaluation (LTE) Process
Dr. Michael Lemieux detailed the lab technology evaluation process, emphasizing the importance of diligent and efficient assessments given the rapidly expanding genetic testing landscape. Avalon reviews evidence from peer-reviewed literature, societal guidelines, and governmental organizations like the FDA and CDC. An independent Clinical Advisory Board (CAB) further strengthens the review process.

Avalon prioritizes customer assistance and collaboration, ensuring transparent and informed reviews. Clients receive scientifically grounded coverage decisions and seamless integration of approved tests into laboratory policies.

Q&A Highlights

• Provider Education: Avalon collaborates with health plans to educate ordering providers on medical policy and PA requirements.
• Credentialing: Avalon gathers necessary documentation for credentialing but the health plan holds the final responsibility.
• Prior Authorization Service: Avalon offers a separate PA service, addressing utilization management and fraud prevention.

Additional resources are available to review, such as Avalon’s lab trend report. The next webinar is scheduled for September.