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 to Texas Medicaid on Proposed MDx Rates

    May 27, 2014
    May 23, 2014 Ms. Greta Rymal Deputy Executive Commissioner for Financial Services State of Texas, Health and Human Services Commission 11209 Metric Blvd, Building H, Mail Code H100 PO Box 85200 Austin, TX 78758 Dear Commissioner Rymal: On behalf of the members of the American Clinical Laboratory Association (ACLA), I am writing to ask you to delay the June 1, 2014, effective date ofContinue Reading »...
  • Bloomberg BNA: Lab Industry Optimistic About New System Based on Private Pay Report Submissions

    April 25, 2014
    An upcoming market-based system for pricing services performed by clinical laboratories is a “better alternative” for the industry than the current Medicare payment system, the president of the American Clinical Laboratory Association said April 23. Although many questions remain to be answered, the system to align Medicare payment rates with the private sector will allow labs to avoid “multiple threats” to reimbursements, ACLA PresidentContinue Reading »...
  • American Clinical Laboratory Association Supports Senate Passage of Provisions for Clinical Laboratory Fee Schedule in SGR Extension Legislation

    April 01, 2014
    WASHINGTON, D.C. – The American Clinical Laboratory Association (ACLA) – a not-for-profit association representing the nation’s leading national and regional clinical laboratories on key federal and state government reimbursement and regulatory policies – voiced support for provisions in the SGR extension legislation passed by the U.S. Senate today that reform the Clinical Laboratory Fee Schedule (CLFS) by providing a more rational process for transitioning toContinue Reading »...
  • A Statement from the American Clinical Laboratory Association (ACLA) on the Clinical Laboratory Fee Schedule (CLFS) provisions in the SGR Extension Legislation

    March 26, 2014
    WASHINGTON, D.C. – The American Clinical Laboratory Association (ACLA) — a not-for-profit association representing the nation’s leading national and regional clinical laboratories on key issues of common concern, including federal and state government reimbursement and regulatory policies –issued the following statement regarding the Clinical Laboratory Fee Schedule (CLFS) provisions in the SGR extension legislation that was posted in the US House of Representatives earlierContinue Reading »...
  • American Clinical Laboratory Association Addresses Medicare Reimbursement Challenges at 2014 Annual Meeting

    March 18, 2014
    Washington, D.C. –  The American Clinical Laboratory Association (ACLA) today opened its 19th Annual Meeting entitled “Navigating the Reimbursement Maze: Challenges and Opportunities Facing Laboratories in the 21st Century,” drawing over 100 clinical laboratory professionals from across the country and featuring health policy experts that will address regulatory policy and funding challenges impacting clinical laboratories.   “As an industry, clinical labs provide the mostContinue Reading »...
  • ‘No rationale’ for Tricare’s refusal to cover genetic tests

    March 11, 2014
    A change in medical classifications last year has left clinical laboratories across the U.S. carrying a $10 million tab for Tricare. Tricare beneficiaries have not been billed for certain physician-ordered tests they have received at clinical laboratories since Jan. 1, 2013 — but Tricare also has not paid for them. At the heart of the standoff are genetic tests developed by laboratories that areContinue Reading »...
  • Congressional Letter to Secretary Hagel about TRICARE

    February 27, 2014
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  • ACLA Statement for House Military Personnel Subcommittee Hearing on Defense Health Agency

    February 26, 2014
    The American Clinical Laboratory Association (ACLA) thanks the Members of the House Military Personnel Subcommittee for consideration of our comments for the hearing, “Defense Health Agency.”  ACLA is a not-for-profit association representing the nation’s leading national and regional clinical laboratories on key issues of common concern, including federal and state government reimbursement and regulatory policies.   Clinical laboratories provide critical testing services to TRICAREContinue Reading »...
  • Lab testing a Medicare cost saver

    February 18, 2014
    Sen. Ron Wyden (D-Ore.), the new chairman of the Senate Finance Committee and a longtime champion of improving chronic disease care, is in a position to play an important role in reforming Medicare. Wyden has long advocated a Medicare program that would feature improved care coordination for chronic disease, which would save lives and improve the quality of life for beneficiaries, while saving MedicareContinue Reading »...
  • Representative Sample of Tests No Longer Covered by TRICARE

    February 10, 2014
      Note: this is not a comprehensive list. For additional reading on this issue, please see the following articles: “DHA operations chief vows some relief from surprise lab fees,” Stars and Stripes, Feb. 6, 2014 “Some lab fees soon will be billed to Tricare patients,” Stars and Stripes, Jan. 9, 2014 Download PDF...
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