ABGC Updates

Studying for Exam Domains 5A and 5C: Legal and Regulatory Requirements and Financial/Reimbursement Issues

 

This article is part of a series by ABGC designed to provide recommendations for additional resources and topics to prepare for the CGC exam. This article covers one exam content category and is meant to provide suggestions based on one genetic counselor’s exam preparation experience. Please note that these are suggestions only and are not meant as an exhaustive guide or exclusive study resource. 

 

In the summer of 2023, we were classmates turned study partners preparing together for the American Board of Genetic Counseling (ABGC) Certification Examination. Since we were located on opposite United States coasts, our co-studying consisted of connecting over video calls. As we embarked on this journey together, we quickly realized that while we had a general idea of how to study, pinpointing how to organize and use our resources was challenging. This was particularly true for domains 5A and 5C of the ABGC content outline, which includes much new information compared to exams dated before August 2023.

If you find studying content related to Legal/Regulatory Requirements (Domain 5C) and Financial/Reimbursement Issues (Domain 5A) daunting, know that we felt the same way! We suggest focusing on the big picture and the main issues rather than getting caught up in institution-specific details. We both approached our board exam preparation by creating detailed outlines containing all of the information we wanted to study. For Domains 5A and 5C, we used the ABGC exam content outline as a starting point and additional resources (described below) to build out our outlines. While this article is not a comprehensive review of these content areas, we hope it can be a starting point for your studies. 

Study Resources Overview

General Resources

Legal and Regulatory Requirements

Financial/Reimbursement Issues

Resource Breakdown

General Resources To Consult

A great place to start when thinking about these topics is “A Guide to Genetic Counseling” by Uhlmann et al. (2009), which is often referred to colloquially as the “Green Book.” Several chapters of this book cover relevant topics. For legal and regulatory requirements, attention should be given to chapter 12, which discusses ethical and legal Issues, and chapter 14, which covers various aspects of research including the elements of an IRB review process. The second half of chapter 9 covers useful information about the oversight of genetic testing through CAP and CLIA. Information on financial and reimbursement issues can be found in chapter 4, specifically in the section on “Billing Issues for Genetic Clinic Visits” and the subsection on “Genetic Testing Fees and Insurance Coverage” (within the “genetic testing” section). Also in chapter 4, tables 4-13 and 4-14 cover billing considerations related to genetic testing and information to include in letters requesting insurance coverage. Finally, chapter 10, which focuses on the ins and outs of medical documentation, covers information related to legal and regulatory requirements as well as billing and reimbursement.

When reading the Green Book, make sure to pay special attention to bolded terms and definitions. Another helpful strategy is to take notes by distilling the information into bullet point summaries. We also found it helpful to discuss some of the chapters with each other to better understand confusing concepts and identify key points. Each of these techniques helped us organize our thoughts and retain more information.

Another resource that we found helpful was “The Genetic Counseling Complete Study Guide” (2nd ed.) by GC Genius which can be purchased directly from their website or on Etsy. This study guide contains a review of information related to Health Insurance Portability and Accountability Act (HIPAA), The Genetic Information Nondiscrimination Act of 2008 (GINA), institutional review board (IRB), ethics, informed consent, medical documentation, as well as billing and insurance.

StudyRare is an additional resource that we found to be a useful source of guidance on what and how to study. StudyRare has many helpful tools including free practice questions which can be found in their monthly newsletter, newsletter archive and on the social platform X. We also found their ABGC Board Review Bootcamp to be an informative supplement to our study toolkits, including for the topics we discuss in this resources article. This review course, as well as tutoring services, can be purchased on their website.

Approach to Legal and Regulatory Requirements: Michaela’s Experience

The broad topics I covered relating to Legal and Regulatory Requirements included GINA, HIPAA, privacy and confidentiality, research standards and regulations, and medical documentation. Many of these topics also relate to ethical principles which largely guide many of the legal policies in place today. Thinking through the connections between these topics when studying is important because the test often incorporates two or more of these concepts into a single question.

Upon achieving a good baseline understanding of each topic using the resources listed above, I took some time to think about each topic individually and gather more specialized information. Below are questions I asked myself about when studying, and some resources that were useful in answering my questions.

  1.  What is HIPAA really?

Prior to studying for boards, I always considered HIPAA a list of rules for what is considered Protected Health Information (PHI). However, this policy also details what security measures are required for protecting PHI and what steps must be taken when a breach occurs. For me, taking the time to read the Health and Human Services (HHS) summary of HIPAA gave me a better understanding of all aspects of HIPAA.

  1.  What information does GINA protect and what are the exceptions to the rule?

GINA was a concept I became familiar with as a prospective student during my first shadowing experience. However, once I looked at it more closely while studying, I realized it was a more nuanced set of rules than I originally understood. Additionally, I learned that GINA works in conjunction with other policies such as the Affordable Care Act, and the Americans with Disabilities act to provide a comprehensive list of protections against discrimination. Reading through the National Human Genome Research Institute (NHGRI) Genetic Discrimination Overview resource gave me a much better understanding of the specific information that is protected through GINA, as opposed to other policies and exceptions to the law.

  1.  What is the relationship between research and ethics?

When thinking through the types of questions I expected the exam to ask about research, I often found myself coming back to ethics. 45 CFR 46, which is the federal regulation for protection of human subjects in research, is founded on the principles of the Belmont report and includes the Common Rule and several other subparts that provide additional protections for research participants. It also outlines the rules by which IRBs are governed. As mentioned above there are several resources that can give you an overview of these documents, but taking time to explore the HHS human research protections website was helpful for me to have a fuller understanding of the rules that govern human research. They have pages dedicated not only to the policies themselves, but also to topics such as informed consent, research involving children and prisoners and rules for IRBs.

While studying legal and regulatory requirements for boards, I realized that while I thought I was familiar with many of these topics, I only had a surface level of knowledge about them. For me, reviewing general study resources was a great place to start when shaping how I studied these topics. This was followed by dedicating just a few of the many hours I spent studying, getting a deeper understanding of each legal and regulatory requirement gave me a great knowledge base to pull from when answering questions on these topics.

Approach to Financial/Reimbursement Issues: Brianna’s Experience

Since many aspects of financial and reimbursement issues are institution specific, for board exam preparation, I focused on issues that are broadly applicable. A guiding question that encompasses many of these issues is: how are genetic counseling services and genetic testing billed for and reimbursed? Below are some focused questions I asked myself, and content resources that may help guide your time studying financial/reimbursement issues.

  1.  How do genetic counselors bill for their time?

While billing practices vary by institution, there are general principles that are useful to understand such as the use of CPT and ICD-10 codes. The NSGC Billing & Reimbursement Toolkit offers detailed information on billing logistics. Keep in mind that many factors determine which billing procedures are appropriate for a given situation, including how a patient will pay for genetics services.

  1.  How do patients pay for genetic counseling and genetic testing services?

Be sure to familiarize yourself with the different payment options available to patients, such as insurance, self-pay and institutional billing. Equally important is learning the main categories of insurance types including private, military, Medicare and Medicaid. The “Billing and Reimbursement” section of “Practical Genetic Counseling for the Laboratory” (Goodenberger et al., 2017) explains these payment and insurance options. If you need an overview of Medicare and Medicaid, there is a detailed video on  AHealthcareZ’s YouTube channel. Additionally, understanding Medicare and Medicaid policies on genetic testing and counseling coverage is a good idea; the FORCE webpage for Medicare and Medicaid Coverage covers relevant information.

  1.  What is the process for obtaining insurance authorization for genetic services?

Obtaining coverage authorization for genetic testing may involve submitting a prior authorization and/or a letter of medical necessity. While the logistics can vary, at a minimum I found it useful to familiarize myself with concepts such as the situations in which these documents are needed, what submissions should include and the steps to take if prior authorization is denied. The Heartland Regional Genetics Network Genetic Testing Toolkit provides valuable information about submitting prior authorizations and writing letters of medical necessity.

Additional Tips and Tricks

We hope the guidance in this article helps you start gathering the necessary information to study Legal/Regulatory Requirements and Financial/Reimbursement Issues. Here are some additional strategies to enhance your study process:

  1. Familiarize yourself with the material: Ensure you understand key concepts such as CPT vs. ICD-10 codes and scenarios not covered by GINA. Utilize memory tools (e.g., mnemonics) or learning tools (e.g., flashcards) to reinforce this knowledge.
  2. Apply practical scenarios: Actively think through real-world scenarios where this material is relevant. For instance:
  • Imagine you need to submit a prior authorization, what essential information must you include?
  • If a prior authorization is approved and the patient asks if their genetic test will definitely be covered, how do you respond?
  • If a patient is worried about losing health coverage due to positive genetic test results, what considerations should you address in your discussion?
  1. Practice writing letters: Write a sample letter of medical necessity or prior authorization request. This hands-on practice can help you become more familiar with the essential components of these letters.
  2. Engage with current events: Following recent news or attending online talks on relevant healthcare regulations and policies can help you understand how these concepts are applied in real-world situations.

References

  • AHealthcareZ-Healthcare Finance Explained. (2021, July 18). Traditional Medicare vs Medicare Advantage vs Medicare Part D vs Medicare Supplement Explained. Youtube. https://www.youtube.com/watch?v=KRzBxPj-eQk  
  • Genetic Counseling Complete Study Guide. (n.d.). GC Genius. Retrieved June 10, 2024, from https://gcgeniusguides.com/products/genetic-counseling-complete-study-guide-91760 
  • Genetic Discrimination. (n.d.). Genome.gov. Retrieved June 10, 2024, from https://www.genome.gov/about-genomics/policy-issues/Genetic-Discrimination
  • Genetic Testing Toolkit. (2021, September 14). Heartland Collaborative. https://www.heartlandcollaborative.org/educational-resources/genetic-testing-toolkit/
  • Goodenberger, M. L., Thomas, B. C., & Kruisselbrink, T. (2017). Practical Genetic Counseling for the Laboratory. Oxford University Press.
  • Medicare & Medicaid Coverage of Genetic Services. (n.d.). Medicare & Medicaid Coverage of Genetic Services. Retrieved June 10, 2024, from https://www.facingourrisk.org/support/insurance-paying-for-care/genetic-services/medicare-medicaid 
  • National Society of Genetic Counselors Coding and Credentialing Workgroup. (2021). BILLING AND REIMBURSEMENT FOR GENETIC COUNSELORS.
  • Office for Civil Rights (OCR). (2008, May 7). Summary of the HIPAA Privacy Rule. HHS.gov; US Department of Health and Human Services. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html
  • Office for Human Research Protections (OHRP). (2016, February 16). 45 CFR 46. HHS.gov; US Department of Health and Human Services. https://www.hhs.gov/ohrp/regulations-and-policy/regulations/45-cfr-46/index.html
  • StudyRare. (n.d.). StudyRare. Retrieved June 10, 2024, from https://www.studyrare.com/
  • Uhlmann, W. R., Schuette, J. L., & Yashar, B. M. (2011). A Guide to Genetic Counseling. John Wiley & Sons.
Tags: ABGC Certification Exam, Exam Content Outline, Domain 5, Legal and Regulatory Requirements, Financial / Reimbursement Issues