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 CMS Proposed Payment Determinations for CLFS 2013

    September 28, 2012
        September 28, 2012   Mr. Glenn McGuirk Centers for Medicare & Medicaid Services Center for Medicare 7500 Security Boulevard Mail Stop C4-01-26 Baltimore, Maryland 21244   Dear Mr. McGuirk:   The American Clinical Laboratory Association (“ACLA”) is pleased to offer its comments on the Centers for Medicare and Medicaid Services’ (“CMS’s” or “the agency’s”) preliminary payment decisions for new and reconsidered ClinicalContinue Reading »...
  • Comments on PFS Proposed Rule for CY 2013

    September 04, 2012
        September 4, 2012   Ms. Marilyn Tavenner, Acting Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Room 445-G Hubert H. Humphrey Building 200 Independence Avenue, S.W. Washington, DC 20201   RE: CMS-1590-P; Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule for CY 2013 – Proposed Rule   Dear Ms. Tavenner:   The American ClinicalContinue Reading »...
  • AIM Letter to Governor Cuomo Regarding NY Self Referral Bill

    July 20, 2012
      July 20, 2012 The Honorable Andrew M. Cuomo Governor of New York State NYS State Capitol Building Albany, NY 12224 RE: Assembly Bill 3551-A/Senate Bill 4660 Dear Governor Cuomo: The Alliance for Integrity in Medicare (AIM), a coalition of organizations committed to ending inappropriate physician self-referral, respectfully requests your veto of AB3551-A/SB4660. This legislation would undermine the New York State Public Health LawContinue Reading »...
  • Letter to Jon Blum Regarding Mitchell Study

    June 01, 2012
      June 1,2012   Jonathan D. Blum Centers for Medicare & Medicaid Services Director, Center for Medicare Management Mail Stop 314G 200 Independence Avenue, S.W. Washington, D.C. 20201   Dear Jon: Thank you very much for meeting with representatives of the College of American Pathologists and ACLA last week. We thought it was a very useful meeting and appreciated the opportunity to discuss pathologyContinue Reading »...
  • Comments to HHS on HPID and ICD-10 Extension Proposed Rule

    May 17, 2012
      May 17, 2012 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: File Code CMS-0040-P RIN 0938-AQ13 Administrative Simplification: Adoption of a Standard for a Unique Health Plan Identifier; Addition to the National Provider Identifier Requirements; and a Change to the Compliance Date for ICD-10-CM andContinue Reading »...
  • Comments on Overpayments Proposed Rule

    April 16, 2012
      April 16, 2012 Ms. Marilyn Tavenner, Acting Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-6037-P P.O. Box 8013 Baltimore, Maryland 21244-8013 RE: RIN 0938-AQ58: Medicare Program; Reporting and Returning Overpayments Dear Ms. Tavenner, The American Clinical Laboratory Association (“ACLA”) appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services’ (“CMS’s” or “the agency’s”)Continue Reading »...
  • AIM Coalition Welcomes Health Affairs Study on Urologist “Self-Referral” of Surgical Pathology Services

    April 10, 2012
      Study by Georgetown’s Jean Mitchell says self-referral is increasing billings for prostate biopsy pathology evaluations, but not improving cancer detection Washington DC – The Alliance for Integrity in Medicare (AIM)—a broad coalition of medical specialty, laboratory, radiation oncology, and medical imaging groups—today applauded publication of a new study which focuses on the practice of self-referral among urologists who conduct prostate biopsy evaluations inContinue Reading »...
  • New Study On Self-Referral Labs: More Tests, Higher Costs, Fewer Cancer Detections

    April 09, 2012
     CAP Urges Immediate Action to Close In-office Loophole in Federal Law NORTHFIELD, Ill. — A new study by researchers at Georgetown University reveals that the practice of ordering tests from pathology labs in which treating physicians have a financial stake resulted in increased utilization, higher Medicare spending, and lower rates of cancer detection. The independent study was published today in Health Affairs and ledContinue Reading »...
  • ACLA Lauds New Health Affairs Study Finding Medicare Costs Rise and Fewer Cancers Are Detected When Physicians Self-Refer for Prostate Cancer Surgical Pathology Services

    April 09, 2012
    Study demonstrates physicians’ financial self-interest may drive unwarranted procedures and unnecessary Medicare spending; highlights the need for Congress to end legal loophole permitting self-referral of surgical pathology services. Washington, DC – The American Clinical Laboratory Association (ACLA) today welcomed a new study published in Health Affairs providing compelling evidence of the increase in government health care spending that results from urologists performing prostate biopsiesContinue Reading »...
  • Comments Regarding Appropriate Use of Clinical Laboratory Testing

    April 04, 2012
      April 4, 2012 ACLA Comments on Choosing Wisely and Appropriate Use of Clinical Laboratory Testing Statement: The American Clinical Laboratory Association welcomes the Choosing Wisely effort and is now reviewing the report. We applaud continued efforts by physicians and medical groups to bring their expertise and evidence to bear in the effort to encourage appropriate utilization of medical testing. We note that mostContinue Reading »...
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