Jul 18, 2016 | Coding, Billing, and Collections, Compliance, Legal, and Malpractice, Laboratory Management and Operations, Laboratory News, Laboratory Operations, Laboratory Pathology, Laboratory Testing, Managed Care Contracts & Payer Reimbursement, Management & Operations
Analysis shows new rule requires data gathering effort that favors larger medical laboratories and thus threatens community labs that serve smaller towns and rural areas
When The Centers for Medicare and Medicaid Services (CMS) issued their Final Rule for lab test market price reporting under the Protecting Access to Medicare Act of 2014 (PAMA) last month, it put the clinical laboratory industry on a path that will have significant financial consequences for all labs, whether large or small. Some experts believe this will be the most disruptive event to the medical laboratory industry in the past 30 years.
By now, the story is well known among pathologists and clinical laboratory directors. That story comes from CMS, which issued the Medicare Clinical Diagnostic Laboratory Tests Payment System Final Rule—AKA the Clinical Laboratory Fee Schedule (CLFS)—that directly affects clinical labs. Under this Final Rule, published in the Federal Register, June 17, 2016, “laboratories and physician offices are required to report private payer rate and volume data if they have more than $12,500 in Medicare revenues from laboratory services on the CLFS and they receive more than 50% of their Medicare revenues from laboratory and physician services during a data collection period. Laboratories will collect private payer data from January 1, 2016 through June 30, 2016 and report it to CMS by March 31, 2017.
“The first data reporting period (that is, the period during which data from the collection period will be submitted to CMS) will be from January 1, 2017, through March 31, 2017. All subsequent data collection and reporting periods for CDLTs [Clinical Diagnostic Laboratory Tests], except for ADLTs [Advanced Diagnostic Laboratory Tests], will follow this same data collection and reporting schedule, every three years. Reporting of private payer rates for ADLTs will occur on the same schedule except it will be on an annual basis,” states the Final Rule. (more…)
Jun 3, 2016 | Laboratory Management and Operations, Laboratory News, Laboratory Pathology, Management & Operations
Medicare’s latest payment rules for joint replacement surgeries is another step forward on the path toward bundled payments and similar value-based reimbursement models
By now, most clinical laboratory managers and pathologists know about an ambitious new Medicare program that essentially brings a value-based reimbursement model to joint replacement surgeries. The program has already commenced in a number of regional markets across the United States.
This new program was instituted by the U.S. Department of Health & Human Services (HHS). It is mandatory program and reimburses providers for hip and knee replacements using a reimbursement model that further ties Medicare payments to quality or value metrics. This program was launched in 67 metropolitan areas.
Called the Comprehensive Care for Joint Replacement (CJR) model, it establishes a 90-day episode of care from the date of the replacement procedure. Hospitals remain accountable for all charges related to recovery and rehabilitation within this window.
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May 9, 2016 | Laboratory Management and Operations, Laboratory News, Laboratory Pathology, Laboratory Testing
Latest calls for easier public access to information on physician performance and quality is a reminder to clinical laboratories and pathology groups of the trend to greater transparency on provider outcomes
If any clinical laboratory executive or pathologist still doubts that more transparency of provider outcomes is a topic of interest to patients, they have only to look at Consumer Reports, well-respected for its advocacy on behalf of consumers. Consumer Reports is using multiple ways to educate their readers about medical errors and how the medical community makes it difficult for consumers to learn about physicians who have been involved in state medical board investigations.
One example is the Consumers Union, which is the policy and advocacy arm of Consumer Reports. Through its Safe Patient Project, the Consumers Union seeks to eliminate medical harm in healthcare.
Consumers Union advocates for increased public disclosure of information about such issues as: (more…)
Mar 14, 2016 | Digital Pathology, Laboratory Management and Operations, Laboratory News, Laboratory Operations, Laboratory Pathology
UnitedHealthcare to cover Foundation Medicine’s comprehensive genomic profiling assay for solid tumors, but Medicare still reluctant to reimburse for genetic tests
Studies showing success of targeted therapies in cancer care may be having an influence on the decisions by certain health insurers to reimburse clinical laboratories to reimburse for certain genetic tests.
One example that press reports cite is how last December UnitedHealthcare began reimbursing for a certain genetic test for patients with a particular lung cancer, according to a statement from Foundation Medicine (NASDAQ:FMI). Based in Cambridge, Massachusetts, Foundation Medicine describes itself as “a molecular information company dedicated to a transformation in cancer care in which treatment is informed by a deep understanding of the genomic changes that contribute to each patient’s unique cancer.” (more…)
Nov 25, 2015 | Compliance, Legal, and Malpractice, Laboratory Management and Operations, Laboratory News, Laboratory Operations, Laboratory Pathology, Managed Care Contracts & Payer Reimbursement, Management & Operations
Clinical laboratories and pathology groups can expect to see more growth in the number of patients served by ACOs and that will require labs to have a new pricing strategy
Will ACOs be the next big thing in American healthcare? Many people are betting that will be true as the number of ACOs continues to increase. Some reports indicate that as many as 750 Medicare and private ACOs were in operation as of early 2015, compared to about 250 ACOs in 2013.
Pathologists and clinical laboratory managers watching the ACO trend will find it significant that Medicare ACOs now serve about 5.6 million beneficiaries. According to a report issued by Oliver Wyman, that is about 11% of all Medicare beneficiaries. Providers in these ACOs are paid under a different arrangement than the long-established Part B fee-for-service price schedule.
The big question mark about ACOs is whether they can deliver significant cost savings while improving patient outcomes. This summer, officials at the federal Centers for Medicare & Medicaid Services (CMS) reported on the savings generated by the agency’s pilot ACO programs. The two main accountable care organization programs are the Medicare Shared Savings Program (MSSP) and the Pioneer ACO Program. (more…)
