Legal Q&A: How to manage cost reimbursement for sequencing and bioinformatics in the respective healthcare systems?

BBMRI.at Legal Helpdesk Service answers

The BBMRI.at Legal Helpdesk Service answers questions on legal and regulatory matters around biobanking and/or using biological samples and data. This service is offered to BBMRI.at partners to support them, as biobanking and research using biological samples and data (e.g. human, animal/veterinary, microbial, etc.) may raise legal questions.

QUESTION:

How is reimbursement for sequencing and bioinformatics managed in healthcare systems?

ANSWER:

There is no uniform Austrian-wide tariff catalogue source for services provided. Reimbursement of genetic testing costs is primarily a responsibility of the individual Austrian states and as a rule is not centrally regulated. Furthermore it is divided between two different types of institutions, depending on whether the patient had been treated in a hospital or in private practice.

1. Reimbursement of genetic testing costs in Austria 

The financial structure and services provided by the Austrian health care sector vary substantially for the 9 individual Austrian federal states (Bundesländer). Therefore, there is no uniform Austrian-wide tariff catalogue source for services provided.

It has been reported that:

“Reimbursement of genetic testing costs is primarily a responsibility of the individual Austrian states and as a rule is not centrally regulated (there are some exceptions). This responsibility is further divided between two different types of institutions, depending on whether the patient had been treated in a hospital (inpatient or outpatient) or in private practice (with a service contract with the relevant health insurance fund). In the first case, the hospital bears the costs of any diagnostic test. The hospital, in turn, is indirectly reimbursed by the health fund of the respective state on a DRG (Diagnosis-Related Group) basis. For private practice, the patient’s health insurance covers the costs. Tariffs are calculated by the health insurance agencies and listed in a catalogue, which is updated annually. However, reimbursement is also possible for tests that are not listed in this catalogue upon individual application. In some instances (for example if the costs exceed a certain threshold), testing requires prior authorization by the chief physician of the insurance agency.

Genetic testing abroad is possible as long as the test is strongly indicated for an individual patient and either a) cannot be performed at all within the country, or b) cannot be performed easily. In these cases, prior authorization by the insurance agency (private practice) or the hospital director is obligatory. Other than that, the general rules described above apply. ”[1] .

For example, the health insurance institution Versicherungsanstalt öffentlich Bediensteter, Eisenbahnen und Bergbau (BVAEB) – responsible for insuring public servants, railroad and mining workers – states that it offers “[…] genetic family consultation, prenatal diagnosis and cytogenetic examinations at contractual partners specialising in this under certain conditions (for tracing the risk of hereditary diseases)”[2] .

Also, genetic testing for different diseases might be subject to different criteria in order to be paid for by the insurance system [3]  or, alternatively, it may require prior approval from the insurance officer to assure reimbursement of that expense[4] or even be subject to a co-payment from the patient.