APILM223880222- CME/CMLE - Laboratory Reimbursement-APILM223880222

APILM223880222 - Educational Activity

Pdf Summary

The commentary by Ann Lambrix, VP RCM Consulting at Vachette Pathology, addresses trends in laboratory reimbursement for 2023 and beyond. The education aims to provide understanding of the Medicare fee schedule for physician and lab services, the impact of the Protecting Access to Medicare Act (PAMA), and methods to mitigate fee schedule cuts.<br /><br />Laboratories typically use two fee schedules: the Medicare Physician Fee Schedule (MPFS) for professional services and the Clinical Laboratory Fee Schedule (CLFS) for automated lab tests. The payment model, primarily fee-for-service, calculates rates using Relative Value Units (RVUs), considering work, practice expenses, and malpractice costs.<br /><br />PAMA has significantly altered how Medicare payment rates are determined, moving toward a market-based system using private payor data. This has led to controversies, particularly regarding the exclusion of many hospital labs from initial data reporting.<br /><br />The pandemic delayed planned reimbursement cuts, but significant fee schedule reductions are slated to begin in 2023. Specifically, the Medicare Physician Fee Schedule is set for an overall 4.4% reduction, while nearly 800 CLFS tests might see drops of up to 15%.<br /><br />Strategies to combat negative impacts include supporting legislation like the Supporting Medicare Providers Act and the Saving Access to Lab Services Act (SALSA), which seek to halt or review fee cuts and improve the collection of representative data. Additionally, labs can adopt cost-reduction strategies focusing on operational efficiencies and leveraging automation. Understanding payor mixes and managing claim denials are also crucial to maintaining revenue cycles.<br /><br />In conclusion, despite the challenging fee schedule landscape, labs must prepare for inevitable cuts by exploring efficiencies and advocating for legislative changes that support fair reimbursement models.

Keywords

laboratory reimbursement

Medicare fee schedule

Protecting Access to Medicare Act

PAMA

Medicare Physician Fee Schedule

Clinical Laboratory Fee Schedule

fee-for-service

Relative Value Units

reimbursement cuts

legislative changes