Reimbursement and Coverage

Clinical laboratories are reimbursed for providing services to Medicare beneficiaries using either the Physician Fee Schedule (PFS) or the Clinical Laboratory Fee Schedule (CLFS), depending on the nature of the service.  In addition, clinical laboratories provide services to beneficiaries of other government programs such as Medicaid, TRICARE and the Federal Employee Health Benefit Plan (FEHBP),…

Clinical laboratories are reimbursed for providing services to Medicare beneficiaries using either the Physician Fee Schedule (PFS) or the Clinical Laboratory Fee Schedule (CLFS), depending on the nature of the service.  In addition, clinical laboratories provide services to beneficiaries of other government programs such as Medicaid, TRICARE and the Federal Employee Health Benefit Plan (FEHBP), as well as commercial plans.

Lab reimbursement in many of these programs has been reduced in recent years, and in the case of the Medicare program, annual cuts are scheduled in current law not only as a result of sequestration, but also through annual cuts built into the Affordable Care Act.

While payments for lab services are being slashed, the costs associated with providing critical laboratory services - including labor, supplies, and transportation - continue to climb.

Although many labs have managed to navigate changes in markets and reimbursement and while still continually improving quality, continued arbitrary and severe payment reductions will result in reduced access to essential tests for critically ill patients, less innovation, more closures or consolidation of businesses, and more people out of jobs.

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  • Comments Regarding 2013 Final Gapfill Prices

    October 30, 2013
    Mr. Marc Hartstein, Director Hospital and Ambulatory Policy Group Center for Medicare Centers for Medicare and Medicaid Services 7500 Security Boulevard Baltimore, Maryland 21244 RE: Final 2013 Gapfill Payment Amounts for Molecular Pathology Tests Dear Marc, Please accept the comments of the American Clinical Laboratory Association (“ACLA”) on the final 2013 Gapfill Payment Amounts for Molecular Pathology Tests.1 ACLA is an association representing clinicalContinue Reading »...
  • Comments on CY 2014 CMS Preliminary Payment Determinations

    October 25, 2013
    Mr. Glenn McGuirk Acting Director, Hospital and Ambulatory Policy Group Centers for Medicare & Medicaid Services Center for Medicare 7500 Security Boulevard Mail Stop C4-01-26 Baltimore, Maryland 21244 Re: Centers for Medicare and Medicaid Services Calendar Year 2014 New and Reconsidered Clinical Laboratory Fee Schedule Test Codes and Preliminary Payment Determinations Dear Mr. McGuirk: On behalf of the American Clinical Laboratory Association (“ACLA”), weContinue Reading »...
  • Bipartisan Group of Senators Urge Medicare Officials to Drop Proposal to Cut Payments for Anatomic Pathology Services

    October 18, 2013
    Washington, D.C. — The American Clinical Laboratory Association (ACLA) praises U.S. Senators Amy Klobuchar (D-MN) and Johnny Isakson (R-GA), and 38 of their colleagues for sending a letter this week urging Centers for Medicare & Medicaid Services (CMS) Administrator Marilyn Tavenner to reconsider cuts to Medicare payments for anatomic pathology services that diagnose breast, prostate, leukemia, and other cancers. Specifically, the letter argues thatContinue Reading »...
  • 115 Members of Congress Urge Medicare Officials to Drop Proposal to Cut Medicare Payments for Pathology Services

    October 10, 2013
    Washington, D.C. — The American Clinical Laboratory Association (ACLA) applauds efforts by U.S. Congressmen Jim Gerlach (R-PA), Bill Pascrell Jr. (D-NJ) and 113 of their colleagues in the House who sent a letter yesterday to Centers for Medicare and Medicaid Services (CMS) Administrator Marilyn Tavenner requesting a withdrawal of a recommendation in the CY 2014 Medicare Physician Fee Schedule Proposed Rule to cut MedicareContinue Reading »...
  • Letter from 115 House of Reps to CMS

    October 07, 2013
    The Honorable Marilyn B. Tavenner Administrator Centers for Medicare and Medicaid Services U.S. Department of Health and Human Services Washington, DC  20201 Dear Administrator  Tavenner: We write to express our strong opposition to a proposal in the Centers for Medicare & Medicaid Services (CMS) proposed rule updating the Medicare physician fee schedule (PFS) rates and policies for calendar year (CY) 2014.  Under the 2014 Medicare PhysicianContinue Reading »...
  • Statement on Revised Gapfill Pricing of the Molecular Diagnostic Codes

    October 01, 2013
    Statement on Revised Gapfill Pricing of the Molecular Diagnostic Codes October 1, 2013 Washington, DC – The American Clinical Laboratory Association (ACLA) issued the following statement on the Centers for Medicare & Medicaid Services’ release of the revised gapfill pricing of the molecular diagnostic codes: “On September 30th, the Centers for Medicare & Medicaid Services released the final carrier prices for the new molecular diagnostic codes, describingContinue Reading »...
  • Letter to Glenn Hackbarth Regarding MedPAC PFS Comments

    September 24, 2013
    Glenn M. Hackbarth, J.D., Chairman Medicare Payment Advisory Commission 425 Eye Street, NW, Suite 701 Washington, DC 20001 Dear Chairman Hackbarth: The American Clinical Laboratory Association is taking this opportunity to share our views on the recent comments submitted to the Centers for Medicare and Medicaid Services (“CMS”) by the Medicare Payment Advisory Commission (“MedPAC” or “the Commission”) with regard to the 2014 MedicareContinue Reading »...
  • ACLA Submits Comments to CMS on Physician Fee Schedule, Clinical Laboratory Fee Schedule Calls For Adequate Reimbursement for Diagnostic Services

    September 03, 2013
    WASHINGTON D.C. – The American Clinical Laboratory Association (ACLA) submitted comments to the Centers for Medicare & Medicaid Services (CMS) urging the use of reimbursement policies that recognize the essential role of diagnostic services in the healthcare delivery system and protects access to these vital services for Medicare beneficiaries. In July CMS issued a rule proposing revisions to payment policies for the Medicare ProgramContinue Reading »...
  • Letter to Marilyn Tavenner regarding PFS Comments

    August 29, 2013
    Administrator Marilyn Tavenner Centers for Medicare and Medicaid Services Department of Health and Human Services Room 445-G Hubert H. Humphrey Building 200 Independence Avenue SW Washington, DC 20201 RE: Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, and Other Revisions to Part B for CY 2014, Proposed Rule (CMS-1600-P) Dear Ms. Tavenner, The American Clinical Laboratory AssociationContinue Reading »...
  • New Analysis Finds Contradictions and Flaws in CMS Rationale for Cutting Anatomic Pathology Services for Medicare Beneficiaries

    August 20, 2013
      WASHINGTON D.C. – Today the American Clinical Laboratory Association (ACLA) released a report prepared by The Moran Company, a research firm with expertise in Medicare, that found serious contradictions and flaws in a recent proposal from the Centers for Medicare & Medicaid Services (CMS) to drastically cut Medicare reimbursement for anatomic pathology services. On July 8, CMS issued a rule proposing to cutContinue Reading »...
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