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Clinical Laboratories and Pathology Groups

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Clinical Laboratories and Pathology Groups

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For more than a year Medicare contractors have been developing payment rates for the 114 molecular tests and without setting rates, they cannot make payments.

New Orleans, Louisiana, April 30, 2013—Getting paid for molecular test claims submitted under the new molecular CPT codes was a subject of high interest on the opening day of the Executive War College. Most clinical laboratories and pathology groups performing molecular tests nationwide report that they have not been paid for invoices submitted to Medicare contractors since January 1, 2013.

Several sessions were devoted to this important topic. Medicare contractors nationwide have not paid many of the molecular diagnostic test claims submitted since January 1 according to speakers and attendees at the first day of The Dark Report’s 18th Annual Executive War College in New Orleans.

Most Clinical Laboratories Waiting for Molecular Test Claims to Be Paid

For more than a year, contractors for the federal Centers for Medicare & Medicaid Services (CMS) have been developing payment rates for the 114 molecular tests in Tier I and Tier II on the 2013 Clinical Laboratory Fee Schedule. As of this date, not all of the nation’s Medicare contractors have published rates, and without the published rates contractors say they are unable to pay invoices for the molecular tests.

alan mertz

Alan Mertz, President of the American Clinical Laboratory Association, presented at Executive War College on reimbursement.

Clinical laboratory companies in California have been hit hardest because so many of them run molecular diagnostic tests.

“The California story is particularly ugly,” observed Michael Arnold, President of the California Clinical Laboratory Association, during a session on reimbursement. “Things are looking pretty dark for the [lab testing] industry. It has gotten to the point where venture capital companies don’t know if they’re going to touch molecular diagnostics companies and genetic medicine now.”

Waiting for All Medicare Contractors to Post Prices

After Arnold spoke, Alan Mertz, President of the American Clinical Laboratory Association, addressed the same session on reimbursement, saying the nation’s medical laboratories expected the Medicare contractors to publish their rates by now. One of the nation’s largest contractors, Palmetto, GBA, said earlier this month it would complete the pricing by May 15.

“We knew this would be a train wreck,” Mertz said of the process Medicare contractors use to set prices. “We asked CMS for a delay, and we asked for more transparency in how the contractors were setting prices. We asked to meet with the contractors. We talked with CMS, and we talked with the contractors.

“We were told that labs should continue to bill for Tier I and Tier II and that way you’ll find out the price,” Mertz added. “We thought that was unusual. It’s a bit like someone applying for a job, and the company saying that the candidate should take the job and work for free for six months. At the end of that time, the company will then tell the jobholder what he or she will be paid.

“A few of our members say prices that have been published so far [by Medicare contractors] are okay and some say the prices are disappointing. But they’re not being paid,” he said.

Attendees Asked about Molecular Test Payments

Earlier in the day, as many as 50 representatives of clinical labs nationwide raised their hands to show that they had not yet been paid for molecular tests billed this year. The show of hands came in response to a request from The Dark Report Publisher Robert L. Michel. Asked to raise their hands to show that they had been paid, only about 10 lab representatives raised their hands.

Both Arnold and Mertz suggested that clinical laboratory executives should ask congress to intervene.

“We’re probably not going to solve this problem by working with the contractors,” Mertz commented. “We will need political help. That’s why I say labs need to talk to your congressman.”

Arnold agreed, saying, “It’s time to get congress and patients involved. If we don’t, we’re going to lose, and patients won’t get the care they need. Call your congressmen.”

“Things are looking pretty dark for the industry, and what California is today, the rest of the country will be tomorrow,” Arnold said.

As Dark Daily reported on April 22 , this situation of labs going unpaid for more than four months is unprecedented and has created financial turmoil and uncertainty across the medical laboratory profession. Forbes columnist Scott Gottlieb has written that this issue is a story of bureaucratic mismanagement.

Day two of the Executive War College will feature speakers who are involved in working with accountable care organizations and developing integrated informatics capabilities for clinical laboratories and anatomic pathology groups. Attendance is at record levels and there are attendees from six different nations around the globe.

—By Joseph Burns 

Related Information:

Forbes Tells the World How Medicare Bollixed Molecular Diagnostic Test Payments, Leaving Nation’s Clinical Laboratories Unpaid for Months

Medicare Has Stopped Paying Bills For Medical Diagnostic Tests. Patients Will Feel The Effects