Failure to Pay for New Molecular CPT Codes Created Money Crisis for Clinical Laboratories and Pathology Groups

Confusion, unhappiness, and many unresolved issues remain about the way government and private payers are handling claims for molecular diagnostic tests covered by the 114 new CPT codes
Dust is settling from the fiasco triggered by the Medicare program’s failure to be ready on January 1, 2013, to settle molecular diagnostic test claims filed under the 114 new Tier 1 and Tier 2 molecular CPT codes. The damage is not just limited to Medicare test claims, but also involves private health plans that were waiting to let the Medicare program set precedents on coverage and prices for the new molecular test codes.

Many Clinical Laboratories Must Cope With an Unsatisfactory Situation

Although federal Medicare officials and Medicare contractors have scrambled to rectify the situation, even today there is much unhappiness across the clinical laboratory industry about the current state of things. That unhappiness extends to state Medicaid and private payers because many of these payers have been slow to publish coverage guidelines and prices for these new molecular test CPT codes.


Failure to Pay for New Molecular CPT Codes Creates Money Crisis for Clinical Laboratories and Pathology Groups

Medicare contractors are setting prices that are 40% to 60% lower than they paid medical laboratories last year for these same molecular diagnostic tests

Non-payment for most new molecular diagnostic test CPT codes continues to be a problem for the majority of medical laboratories across the country.

A lack of payment for these claims, have forced some clinical laboratories and pathology groups to stop doing molecular testing and lay off staff. At least one lab  company shut its doors, blaming non-payment by its Medicare contractor as the primary reason.