You may know Sara Pirzadeh-Miller in her role as the Director of the Cancer Genetics Program at UT Southwestern (UTSW), or as the President Elect of NSGC … but do you know her as a trail blazer and champion in genetic counseling reimbursement??
I interviewed Sara about her role in reimbursement and learned that her center, like many, didn’t bill for cancer genetic counseling for many years. In 2019 her cancer center leadership decided to start billing and they took it head on, billing CPT code 96040 in December 2019. But they didn’t just start billing. Sara and the GC team worked with their finance team to closely track reimbursement and denial data. About 6-9 months into the project, they noticed that UT Select (the UTSW employee insurance provider, under Blue Cross/Blue Shield of Texas) was denying claims for cancer genetic counseling services. They took a deep dive into ‘why’ and learned that it was a ‘provider type’ denial code — meaning, while the CPT code was recognized a covered benefit under the plan, they weren’t paying because genetic counselors were not appropriately recognized as the only providers of GC care under the code! This is in direct contrast with the code’s summary, below. Therefore, Sara and her team started conversations with UTSW and UT System leadership in Fall 2020, who connected them with the right people at UT Select and BC/BS TX. After review, BC/BS TX realized they needed to recognize GCs as the only true billable providers of GC services, as written in the CPT code. After recognition of their error, the fix was put into place for prospective billing in October 2023. After following the charges before and after October 2023, they were able to confirm that reimbursement for GC service was indeed happening! This fix allows all GCs, who are credentialed with their institutions, seeing BCBS TX beneficiaries to get paid appropriately for their 96040 charges.
Sara’s advice to other genetic counselors who want to get GC reimbursement for your services:
-Figure out who you need to talk to at your institution. Start with your finance and billing & reimbursement teams.
-Build relationships.
-Track it. Keep meticulous records.
-This takes work and time. But from a sustainability perspective, this is critical to the future of our profession.
-You don’t want to leave money on the table that we can use to support our GC services and growth of your genetic counseling program.
-Keep fighting the good fight. We have to promote this. You can do it!
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