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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  • Letter from CLC to HHS OIG Meeting Request

    July 11, 2013
      Daniel R. Levinson Inspector General Department of Health and Human Services Office of Inspector General 330 Independence Avenue, SW Washington, DC 20201 Dear Mr. Levinson: On behalf of the undersigned organizations—representing America’s community, regional, hospital-based, and national clinical laboratories; the laboratory professionals who provide care for the Medicare patients we serve; and diagnostic manufacturers—we write to request a meeting with your office toContinue Reading »...
  • Statement on CMS Proposed Physician Fee Schedule Rule

    July 09, 2013
    WASHINGTON, DC – The American Clinical Laboratory Association (ACLA) issued the following statement on the proposed rule published today in the Federal Register by the Centers for Medicare and Medicaid Services (CMS), “Medicare Program: Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions for Part B for CY 2014” (the “Proposed Rule”): ACLA is deeply concerned withContinue Reading »...
  • Statement on CMS Proposed Physician Fee Schedule Rule

    July 09, 2013
    WASHINGTON, DC – The American Clinical Laboratory Association (ACLA) issued the following statement on the proposed rule published today in the Federal Register by the Centers for Medicare and Medicaid Services (CMS), “Medicare Program: Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions for Part B for CY 2014” (the “Proposed Rule”): ACLA is deeply concerned withContinue Reading »...
  • ACLA Submits Comments on Gapfill Pricing for Molecular Pathology Services

    July 02, 2013
    (WASHINGTON, D.C.) The American Clinical Laboratory Association (ACLA) submitted comments today to the Centers for Medicare & Medicaid Services’ (CMS) regarding the agency’s 2013 gapfill pricing under the Clinical Laboratory Fee Schedule (CLFS) for molecular pathology services. For 2013, CMS decided to use the gapfilling methodology to establish payment rates for more than 100 new Tier I and Tier II molecular pathology test codesContinue Reading »...
  • Statement Regarding OIG Report on Medicare Spending on Clinical Lab Services

    June 12, 2013
    Washington, D.C. (June 12, 2013) – The Department of Health and Human Services (HHS) Office of Inspector General (OIG) yesterday released a report, “Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings.” The report examined 20 of the 1100 laboratory test codes (HCPCS) and concluded that Medicare paid “more than other insurers” for these codes. The American Clinical Laboratory Association (ACLA) saw theContinue Reading »...
  • Letter to CMS Regarding Gap Fill

    April 30, 2013
      Marilyn B. Tavenner Administrator Centers for Medicare and Medicaid Services U.S. Department of Health and Human Services 200 Independence Ave., SW Washington, DC 20201 Dear Administrator Tavenner: We are a coalition of patients, providers, clinical laboratories, diagnostic test manufacturers, pharmaceutical companies, and venture capital investors unified in our concern over interim 2013 Medicare Administrative Contractor (MAC) reimbursement rates for molecular diagnostic testing. ThisContinue Reading »...
  • Letter to Sens Baucus and Hatch Regarding Clinical Laboratory Fee Schedule

    April 16, 2013
      The Honorable Max Baucus Chairman, Committee on Finance United States Senate 219 Dirksen Senate Office Building Washington, DC 20510 The Honorable Orrin Hatch Ranking Member, Committee on Finance United States Senate 219 Dirksen Senate Office Building Washington, DC 20510 Dear Chairman Baucus and Ranking Member Hatch: On behalf of the undersigned organizations—representing America’s community, regional, hospital-based, and national clinical laboratories; the laboratory professionalsContinue Reading »...
  • ACLA Opposes Further Cuts To Clinical Laboratories In President’s 2014 Budget – Proposal Would Cut Lab Reimbursement By An Additional 14% Over Ten Years

    April 10, 2013
    (Washington, DC) – The American Clinical Laboratory Association (ACLA) strongly opposes a proposal in the President’s 2014 budget that would reduce reimbursement for clinical laboratory services in Medicare by an additional $9.460 billion over ten years, a cut of at least 14% over ten years. This proposal, on top of the cuts already scheduled under current law, would bring total cuts to the ClinicalContinue Reading »...
  • Letter Regarding Gapfilling for Molecular Pathology Tests

    March 27, 2013
      Mr. Marc Hartstein Director, Hospital and Ambulatory Policy Group Centers for Medicare and Medicaid Services Mail Stop C4-01-26 7500 Security Boulevard Baltimore, MD 21244 RE: Gapfilling for Molecular Pathology Tests Dear Marc: I am writing on behalf of ACLA to follow-up on our prior conversations regarding the gapfilling process for new molecular pathology codes, which CMS has mandated. As you know, in theContinue Reading »...
  • CLC Letter to Sen Baucus Regarding Clinical Lab Fee Schedule

    February 15, 2013
      February 15, 2012 The Honorable Max Baucus United States Senate 511 Hart Senate Office Building Washington, DC 20510 Dear Senator Baucus: The undersigned laboratory and health care organizations, representing America’s community, regional, and national laboratories and the Medicare patients we serve, ask that you oppose any cuts to the Medicare Part B Clinical Laboratory Fee Schedule as you work to address physician payContinue Reading »...
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