在医疗保险中与癌症相关的下一代测序的索赔拒绝
So-Yeon Kang1, Ilina Odouard2, Carole Roan Gresenz1,3
1Department of Health Management and Policy, Georgetown University School of Health, Washington, DC.
JAMA network open
|April 18, 2025
概括
在国家覆盖确定 (NCD) 后,下一代测序 (NGS) 癌症测试的保险索赔拒绝增加. 对于在独立实验室进行的测试和更全面的基因组分析,否认率更高.
科学领域:
- 在瘤学瘤学.
- 基因组学就是基因组学.
- 医疗保健服务研究 医疗服务研究
背景情况:
- 美国医疗保险和医疗补助服务中心 (CMS) 在2018年为下一代测序 (NGS) 基因测试制定了国家覆盖率确定 (NCD),并于2020年修订.
- 了解NGS保险索赔拒绝的频率和原因对于患者获取和医疗保健费用至关重要.
研究的目的:
- 调查Medicare受益人中NGS测试索赔拒绝的普遍性和相关因素.
- 分析NCD实施和修订如何影响NGS测试索赔拒绝率.
主要方法:
- 一项队列研究分析了2016年至2021年20%的医疗保险索赔数据样本.
- 多变量后勤回归模型确定了与索赔拒绝相关的因素,包括与NCD相对的测试类型,地点和时间段.
主要成果:
- 与癌症相关的NGS测试索赔从2016年到2021年大幅增加.
- 整体索赔拒绝率为23.3%,比率从NCD前的16.8%增加到NCD后的27.4%.
- 如果在独立实验室进行 (OR 2.76) 或对更多的基因 (OR 1.32) 进行索赔,则更有可能被拒绝.
结论:
- 根据测试地点和类型,NGS测试索赔拒绝率各不相同,并且随着时间的推移而增加,特别是在NCD之后.
- 这些发现表明,尽管有NCD,NGS覆盖范围仍存在不确定性.
- 需要采取政策干预措施,以减少NGS测试的覆盖不确定性和财务责任.
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