Operations and Implementation

ePoster Presentation

(EP-149) The Impact of a Telehealth Program on Insurance Coverage for Genetic Testing in Puerto Rico

Monday, April 24
6:00 PM - 6:15 PM
Location: Experience Zone - ePosters

Background –Since 2010, the Lopez Family Foundation (LFF) has been supporting a Telehealth Program in Puerto Rico (PR), including a Tele-Genetics clinic, directed by Children’s Hospital Los Angeles (CHLA). In order to provide the appropriate care and follow-up for patients from the Tele-Genetics clinic, it is imperative that the children have genetic laboratory tests performed that are recommended by the geneticist. Most genetic tests have not been covered by Reforma, the Medicaid-insurance in PR, historically however given our presence and our impact on care provided to patients with genetic disorders, we have been able to see a shift on lab coverage for critical genetic lab testing. Therefore, this kind of impact shows that a telehealth program such as the Lopez Family Foundation Telehealth Program in Puerto Rico can affect pivotal policy changes in order to address medically necessary services such as genetic testing.
Methods – By phone calls to the different Reforma health insurance programs in PR, performed by the billing department of the Pediatric University Hospital where the Tele-Genetics clinic is located, we were able to develop the correct process that the families need to follow in order to have genetic tests covered by their insurance. After collecting this information, the Telehealth Clinical Program Coordinator (TCPC) has been orienting the families on the correct process to get their tests approved by their insurance. The laboratories we are using to have tests done that are covered by the LFF are 3 main laboratories that perform genetic tests: High Profile Lab, Genetic Solutions Lab and San Jorge Children’s Hospital Lab. The choice of lab is determined by a process of the labs’ offering to perform a test that the geneticist has recommended for a certain amount of money, and the TCPC coordinates these test proposals with the geneticist, who makes the final determination. If tests are to be covered by Reforma the patient goes to their preferred laboratories accepting Reforma. The process is: (1) the families need to collect a CPT code(s) at a laboratory of their preference;(2) they have to go to their primary care physician (PCP) to have a special application form for the genetic test filled out, (3) their PCP or themselves need to submit that information along with the report of the outpatient genetic consultation to the insurance; (4) if the insurance still denies the test, they can submit an appeal letter; (5) if t’s finally approved, they must go to the same lab where they got the CPT code for the test.
Results – After developing the information, orienting the families on the process and putting a step-by-step document on the clinic’s door, we have managed to get 30% (13 patients) from FY 2016 of patients covered by Reforma. Among these were fragile X DNA, chromosome microarrays, metabolic tests, Angelman syndrome test, and DNA test for mutation of CFTR gene of patients from FY 2016 have their tests covered by their insurance. Still 51% (22 patients) were covered by the LFF Lab Assistance Program. The difference is that in the past cero were covered by the insurance and all genetic tests ordered had to be paid for by the LFF Lab Assistance Program.
Challenges – Given that the Tele-genetics service is sponsored by a not-for-profit organization and we do not have a contract to bill the insurance companies, we were not able to get any information about this process ourselves directly from the insurance companies, so we had to rely on the information about the process for obtaining tests covered by Reforma to be collected by a person, at the Pediatric University Hospital Billing Department. The Department of Health has indicated at previous meetings that they have no saying in what the Reforma’s insurance companies decide
Conclusion – We still have a lot of work to do in order to provide the families with a recommended testing and therefore follow-up in the tele-genetics clinic. Still 30 % is a great improvement compared to none in previous fiscal years. The tele-genetics program is very important to the pediatric population in PR and to their families, given that there are only 3 doctors in this specialty on the island and only one of the three serves the population we serve.
1. Viewers will acknowledge the complicated process that puertorrican families have to encounter in order to have genetic tests done, either by their insurance or by the LFF Lab Assistance Program.
2. Viewers will understand the process for billing to PR’s Medicaid insurance (Reforma).
3. Viewers will describe the process the families need to undergo in order for their genetic tests to be done by their Medicaid (Reforma) insurance.

Learning Objectives:

Cristina Aquino-Quinones

Telehealth Clinical Program Leader
Children's Hospital Los Angeles / Lopez Family Foundation

Cristina is a nurse who finished her BSN in 2005 from the UPR at Mayaguez, Puerto Rico. She then finished her Masters Degree from Primary Health on 2009. Most of her experience has been in Emergency Rooms. She began working with telemedicine in a Research facility in 2012 and then started to work for Children's Hospital Los Angeles and the Lopez Family Foundation as of 2013, currently holds a role of Telehealth Clinical Program Leader.


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Linda M. Randolph

Children's Hospital Los Angeles / Lopez Family Foundation

M.D., FAAP, FACMG; Head, Division of Medical Genetics


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Ryan Navarro

Children's Hospital Los Angeles / Lopez Family Foundation

MHA, Administrator, International Telehealth


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(EP-149) The Impact of a Telehealth Program on Insurance Coverage for Genetic Testing in Puerto Rico

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