Three Rivers Provider Network (“TRPN”) claims to be the largest supplemental PPO Network Foundation in the US, providing healthcare benefits to more than 10 million members, at more than 1 million locations nationwide.
Under the agreement, BREVAGen™ patients covered by insurers that are part of the TRP Network will have their claims adjudicated as “in network”, expediting the claim processing at an agreed discount.
The agreement with TRPN is the fifth such credentialing agreement executed between the Company and similar US Preferred Provider Organisations (“PPOs”) and increases the total number of covered lives, for which its BREVAGen™ test could be adjudicated as “in-network”, to more than 23 million.
The impact of this credentialing has been clearly demonstrated in reviewing reimbursement claims for the BREVAGen™ test since its launch. As reported recently by the Company in its March 2013 Quarterly Activities Report, the average reimbursement received in respect of claims that were adjudicated as “innetwork” was more than 25% higher than the amounts received in respect of claims that were adjudicated as “out of network”, with the time taken to collect the funds also being materially shorter.
Importance of credentialing contracts executed with Preferred Provider Organisations
As mentioned, credentialing with PPOs such as TRPN allows for expedited claim adjudication as “innetwork”. This provides improved cash flow via faster payment while still obtaining an acceptable level of reimbursement, and also reduces the costs incurred through appealing denials. Once BREVAGen™ sample volumes reach a significant level and Genetic Technologies has gathered any necessary clinical utility data, the Company will approach insurers directly to contract.
A PPO is a managed care organisation of medical doctors, hospitals and other health care providers who has covenanted with an insurer or a third-party administrator to provide health care at reduced rates to the insurer’s or administrator’s clients. Credentialing is a process whereby provider organisations such as physicians, care facilities and ancillary providers (including testing service providers such as GTG’s subsidiary, Phenogen Sciences) contract directly with the PPO. Contracts with PPOs are fundamental to having claims for the BREVAGen™ test adjudicated “in-network”.
Credentialing contracts have now been executed with Three Rivers Provider Network, Prime Health Services, National Preferred Provider Network / PlanCare America / Ohio Preferred Provider Network LLC (NPPN / OPPN), Galaxy Health Network and Fortified Provider Network. The Company is now actively pursuing agreements with other PPOs in order to further extend access to an increased number of covered lives.