Empower is a genetic test for those who want to know more about their risk of developing cancer, why it might be common in their family, or want to inform treatment options following a cancer diagnosis.
Billing agents must handle Empower Breast Cancer cases. It screens for BRCA 1 and 2 (breast cancer) and up to 51 other genes.
High Risk VS Low Risk
High risk is assigned when a patient has a personal history, or at least 2 relatives listed on the Requisition Form (The relatives considered close in determining high risk for the patient include: father, mother, siblings, and children), or by diagnosis code (ICD10).
- To find the ICD-10 code, go to AMD / History, double-click on the black row.
- Click on the 3 black dots on the ICD-10 code to determine if it is high-risk or low-risk.
- Any ICD-10 code that includes the word “malignant” in its description is typically considered HIGH RISK
Low risk is assigned when a patient has no personal history and 1 or 0 relatives listed on the Requisition Form.
- If the Family/Personal history is blank, the case will default to low-risk
- A high-risk person can be assigned as low risk if they do not complete the History form or do not have high-risk diagnosis code(s) on the Requisition Form.
Self-pay patients will apply for a prompt-pay rate of $249 for the first 30 days after the bill is generated, and the full cash price out of pocket will be $499.
HOW DOES INSURANCE COVER EMPOWER?
–Medicare(Traditional) For Empower Covered- the patient is not expected to have an out-of-pocket.
–Medicaid (Traditional) For Empower Covered- the patient is not expected to have an out-of-pocket.
–Commercial Plan For Empower, we will bill the patient for co-pay, deductible, and coinsurance per the EOB and insurance plan.
-Commercial Plan ended up on NCS
- For Empower, we offer the patient $249 prompt-pay rate
-Tricare(military health benefit)
- Empower will be covered, but we will bill the patient for deductible/coinsurance/ co-pay based on the plan.
HIGH RISK
BRCA 1 and 2 are covered for patients who are at HIGH RISK at no cost to the patient
It is considered “preventive” care under the Affordable Care Act (ACA), so even if a patient has coinsurance or deductible, it does not apply due to ACA coverage guidelines.
High-risk patients with OON insurance will likely have Patient Responsibility after insurance (ACA guidelines do not apply)
LOW RISK
Those who do not have a personal or family history are Low-risk
BRCA 1 and 2 are likely not covered for patients who are low-risk, and patients may incur a cost after the claim is processed through the insurance company.
CPT CODES FOR EMPOWER BREAST CANCER
Commercial + Government A La Carte:
81162 – List Price $1999
Government Panels
81432 – $1000
81433 – $999
The total list price is $1999
General Empower Billing Message
When taking an Empower test, patients will receive a message stating:
“Your health plan may cover the cost of your Empower test based on your personal and family health history. If your health plan covers the test, you’re not expected to pay anything out of pocket. If your health plan does not cover the test, Natera offers a discounted price of $249 to ensure it is affordable.”
Patients with positive results will be covered 100% by the insurance.
IF THE PATIENT SAYS THEY SHOULD OWE $0
If the Requisition Form has Low-Risk diagnosis codes provided by the physician and the patient says they owe $0, please say:
- “Sometimes insurance payment is based on whether you are high risk or low risk. Let me check how your doctor ordered the test.”
- After checking the Req Form, “It looks like your doctor submitted low-risk diagnosis codes, so that’s likely why your insurance didn’t pay.”
If the Requisition Form shows High-Risk diagnosis codes and the patient says they owe $0
- Please transfer the patient to Natera Escalations. They will send a courtesy exception request so that the case can be reviewed. Do not guarantee anything!
If the case was denied due to missing Prior Authorization and the patient’s history is blank on the Requisition Form OR they have High-Risk DX codes
- Please transfer the patient to Natera Escalations. They will send a courtesy exception request so that the case can be reviewed. Do not guarantee anything!
If the EOB says they owe a PR and the patient says they owe $0
- Please ask patients to send the complete copy of their EOB to [email protected], and after it has been received, our back office team will be one in charge of completing the process
REGARDLESS IF PATIENTS ARE SELF-PAY OR A CLAIM WAS PROCESSED THROUGH THE INSURANCE, AND THERE’S A PR, PATIENTS ARE ELIGIBLE FOR WALK-DOWN OPTIONS, INCLUDING COMPASSIONATE CARE
Last update by: Claudia F (November 19, 2024)