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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  • AIM Letter to Rep. Speier on Promoting Integrity in Medicare Act of 2013

    August 01, 2013
      The Honorable Jackie Speier U.S. House of Representatives 211 Cannon House Office Building Washington,DC 20515 Dear Representative Speier: On behalf of the members of the Alliance for Integrity in Medicare (AIM) — a broad coalition of medical specialty, laboratory, radiation oncology, and medical imaging groups committed to ending the practice of inappropriate physician self-referral — we thank you for introducing The Promoting IntegrityContinue Reading »...
  • Joint Statement By The Alliance For Integrity In Medicare Applauding THE Introduction Of The Promoting Integrity In Medicare Act Of 2013 By U.S. Representative Jackie Speier (D-CA14)

    August 01, 2013
    JOINT STATEMENT BY THE ALLIANCE FOR INTEGRITY IN MEDICARE APPLAUDING THE INTRODUCTION OF THE PROMOTING INTEGRITY IN MEDICARE ACT OF 2013 BY U.S. REPRESENTATIVE JACKIE SPEIER (D-CA14) August 1, 2013 The Alliance for Integrity in Medicare (AIM)— a broad coalition of medical specialty, laboratory, radiation oncology, and medical imaging groups committed to ending the practice of inappropriate physician self-referral – applauds the strong leadershipContinue Reading »...
  • Comment on Promoting Integrity in Medicare Act of 2013

    July 30, 2013
    The Honorable Jackie Speier U.S. House of Representatives 211 Cannon House Office Building Washington, DC 20515 Dear Representative Speier: The American Clinical Laboratory Association (ACLA) represents the nation’s leading local, regional and national laboratories, many of whom provide anatomic pathology services. Therefore, we thank you for introducing The Promoting Integrity in Medicare Act of 2013, which realigns provider incentives to preclude self-referral by noContinue Reading »...
  • Joint Statement from the Alliance for Integrity in Medicare on the GAO Report on Self-Referral Leading to Over-utilization of Pathology Services

    July 16, 2013
    The Alliance for Integrity in Medicare (AIM)—a broad coalition of physical therapy, laboratory, radiation oncology, and medical imaging groups committed to ending the practice of inappropriate physician self-referral—applauds the findings of the Government Accountability Office (GAO) released July 15, 2013, “Action Needed to Address Higher Use of Anatomic Pathology Services by Providers Who Self-Refer.” AIM believes these findings add significantly to the existing mountainContinue Reading »...
  • ACLA Applauds GAO Report Finding Financial Incentives Drive Anatomical Pathology Self-Referral Practices in Medicare

    July 16, 2013
    Washington, DC – The American Clinical Laboratory Association (ACLA) applauds the release of the new Government Accountability Office (GAO) Report to Congress, examining self-referral practices within Medicare for anatomic pathology services. Entitled “Action Needed to Address Higher Use of Anatomic Pathology Services by Providers Who Self-Refer (GAO-12-455),” this study investigated the impact of self-referral on anatomic pathology services, which play a critical role inContinue Reading »...
  • 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 »...
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