Case Study: Fallon Health achieves 75% faster MDx prior-authorization decisions with Optum’s DEX™ Diagnostics Exchange

Fallon Health Makes MDx Authorization Decisions 75% Faster with the DEX™ Diagnostics Exchange

Fallon Health, a Massachusetts-based payer serving about 213,000 members, faced a rapid threefold rise in molecular diagnostic (MDx) test requests and struggled to determine test appropriateness. Prior authorizations required about 10 hours over three to four days per request as staff manually researched tests and criteria. Fallon turned to Optum’s DEX™ Diagnostics Exchange (with DEX Z‑Code™ identifiers and InterQual® MDx Criteria) to gain clarity on which specific tests were being ordered and which criteria applied.

Optum implemented DEX via web access, training, and a phased rollout to Fallon’s lab networks, requiring no IT development. The solution cut prior‑authorization review time by 75% to roughly one hour per request, producing more than $100,000 in administrative savings in six months, an estimated $46,000 in medical cost avoidance, and a 10% reduction in PMPM MDx spend—projecting roughly a 4x ROI over five years. DEX Z‑Codes improved test differentiation (miscellaneous code billings fell dramatically), reduced billed lines per member by 19%, and improved collaboration with physicians and labs.

Fallon Health

Pamela Cardaci

Senior Director of Utilization Management and Prior Authorization