Steve Morgan – Avalon Healthcare Solutions

Testing, testing: Avalon and CLO help health insurers make coverage choices

It’s not just patients whose patience is tested by the seemingly endless tests they may undergo during even routine checkups and exams.

As Steve Morgan says, approximately 3/4 of healthcare decisions originate from lab test results and more than 14 billion tests are performed annually in the U.S. at a cost of $82 billion. For example, the number of genetic tests on the market has more than doubled since 2017, from approximately 75,000 to 175,000 genetic tests now available.

Morgan keeps his eyes on the market because he’s the chief legal officer for Avalon Healthcare Solutions, a Tampa, Florida-based company that enables real-time use of laboratory insights in health plan claim processing environments. Founded in 2013, Avalon employs teams of experts that assess current science and make recommendations to health plans in the form of laboratory policies regarding which tests should be covered and under what circumstances. Avalon can identify non-compliant claims, which oftentimes represent avoidable waste, Morgan says.

“Avalon takes the best available science and brings it to health plans so they can scale it,” he says. “Our motto is ‘science is our true north,’ and we assess what’s scientifically supportable. This enables health plans to realize cost savings and to invest in population health initiatives.”

Expert advice

Avalon’s expert teams are comprised of an internal group of Ph.D.s and M.D.s who are tasked with monitoring the pipeline of new tests used throughout the healthcare industry. Avalon also maintains an external, independent clinical advisory board to oversee the company’s laboratory policy development and maintenance process.

The clinical advisory board is comprised of five doctors with expertise in fields including hematology, laboratory science, molecular genetics and pathology. They work with 130 Avalon lab policies regarding items such as Vitamin D and toxicology/illicit drug use to inform the platforms and solutions the company provides its customers.

Morgan says the plethora of genetic tests hitting the market almost daily presents issues for health insurance plans in terms of how effective they are for diagnosing and treating patients. Among Avalon’s recent innovations is its “precision genetic testing management” solution, which will be launched during the second half of 2023.

The tool helps plans and providers by minimizing, and at times eliminating, the time-consuming process of determining prior authorizations and coverage for using a genetic test. It does so by enabling insurance companies to quickly obtain a test’s five-character alpha-numeric code from the rendering lab provider—preventing delays in administering a test or processing a claim afterward.

“When you do things like that, it’s a quadruple win because it benefits physicians, patients, providers and plans,” Morgan says.

He points out that there is no “one size fits all” approach to laboratory policy development. While science should be irrefutable, it is also evolving. Moreover, what ultimately is codified as laboratory policy may vary from plan to plan depending on the plan’s unique needs, such as line of business-specific variations and department of insurance requirements.

Morgan says Avalon executives and board members meet at least quarterly with the company’s quality and compliance teams while he collaborates with business teams to ensure proposed services and products are compliant.

“Detecting issues is one indicator that a compliance program is effective,” he says. “There’s never a substitute for sitting down with people and understanding what they’re working on and issues they face early on without any kind of punitive approach.”

Family influence

Born and raised in St. Louis, Morgan says he followed a family tradition in becoming an attorney—his father and sister are litigators.

“I can’t tell you how many family dinners were really moot court presentations,” he jokes.

However, Morgan says it was his mother, a child psychologist who also taught English, who taught him how to write and shape arguments into essay form. Her tutelage continued even as he began studying at the University of Missouri-Columbia, and he, in turn, volunteered at the university’s writing lab.

After earning his bachelor’s degree in 1997, Morgan continued to Saint Louis University School of Law. He earned his J.D. in 2001 while also serving as president of the university’s health law association, senior articles editor for the Journal of Health Law and competing in the National Health Law Moot Court.

While earning his J.D., Morgan also earned his master’s degree in health administration from Saint Louis University School of Public Health. He also has an MBA he earned in 2011 from the University of Missouri-Saint Louis College of Business Administration.

The practice chose him

His enthusiasm for health law occurred because of an accident he suffered rock climbing while studying for his bachelor’s degree. Morgan recovered from a fall that broke his back in five places and says the trauma sharpened his vision of what he wanted to do with his life.

While in law school, he also served an externship with the U.S. Department of Justice in its Medicare Criminal and Civil Fraud Enforcement units researching fraud litigation. After graduating, he joined the firm of McDermott Will & Emery in Washington, D.C., where he’d been a summer associate and provided regulatory and contracting support to managed care organizations, healthcare providers and pharmaceutical manufacturers.

In 2004, Morgan became an associate attorney at Wiley Rein LLP, where his practice included advising health plans and federal government contractors regarding bid protests and bid defenses.

A year later, he moved in-house when he joined Express Scripts, a pharmacy benefit manager, as legal counsel. He worked closely with the specialty pharmacy teams while there. He was named senior counsel in 2009 and then assistant general counsel in 2010. In April 2012, he was named vice president and associate general counsel, the position he held before joining Avalon.

“I was selected because my background was compelling to the CEO and the board as an attorney who understands healthcare regulatory and transactional matters,” Morgan recalls. “I was younger then, and I took the personal and professional risk to join a start-up company. Now, I’m part of a solution that improves our healthcare system by eliminating avoidable waste, speeding up antiquated processes, and ensuring equitable and consistent administration of precision healthcare resources.”

View this feature in the Vanguard Fall I 2023 Edition here.

Published on: August 18, 2023



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