Reimbursement & Policy Outlook for Labs in 2019

For the clinical laboratory industry, look for 2019 to be another challenging year on the reimbursement front as a second round of Medicare cuts of up to 10 percent for many lab tests take effect under a market-based fee schedule required by the Protecting Access to Medicare Act (PAMA).

• Relentless reimbursement pressure on providers
• Emphasis on contracting & value-based care
• Increasing patient financial responsibility 
• Growing numbers of physicians are becoming employees
• Rise of healthcare consumerism plus move to retail environment
• Integrating personalized medicine into clinical practice — molecular diagnostics, genetic testing & gene sequencing/NGS

• PAMA is the first reform of the Clinical Laboratory Fee Schedule (CLFS) since 1984
• For the first time, it ties Medicare payment rates for lab tests to those paid by private payers rather than based on historical charges made by labs at local level as done previously  
• It creates a single national fee schedule with no geographic adjustment, annual update or budget neutrality adjustment
• There continues to be no Part B co-payment or deductible for lab services

• Covered under Medicare Part B
• Offered and finished by only one lab 
• Not sold for use by a lab other than the lab that designed the test or a successor
• Either cleared or approved by the FDA or, 
• Is an analysis of multiple biomarkers of DNA, RNA or proteins, and
  • When combined with a unique algorithm, yields a patient specific result, and
  • Provides new clinical diagnostic information that cannot be obtained from any other tests to combination of tests, and
  • May include other assays

• Lab industry will continue to encounter severe pricing pressure for the next few years (2020)
• Total national spending for lab testing will be flat through 2020 as first three years of Medicare’s new market-based pricing take full effect
• Gradual drop in fee-for-service payments,, growing problems with being out-of network and more fixed fee arrangements such as contracting & bundling 
• Growing patient responsibility will require labs to collect greater percentage of revenue from patients

Intended audience

This continuing education credit is intended for use by clinical laboratory professionals who are interested in learning about the current reimbursement environment and the 2019 policy outlook.

Take the course and obtain CE credits

Attend this basic level webinars at no cost.  Cardinal Health is approved as a provider of continuing education programs in the clinical laboratory sciences by the ASCLS P.A.C.E.® Program.  This webinar is managed by Whitehat Communications and offer one P.A.C.E.® Continuing Education contact hour for up to six months after the live event.

One P.A.C.E.® credit is available upon completion of the course: Reimbursement & Policy Outlook for Labs in 2019

P.A.C.E.® credits are widely recognized in the clinical laboratory profession and can be used to fulfill most continuing education requirements.