Updates To 2018 Medicare Physician Fee Schedule Impact Clinical Diagnostic Labs
Medical laboratories play a crucial role in healthcare by providing vital diagnostic information to physicians for making accurate diagnoses and treatment decisions. In the United States, Medicare is a major payer for laboratory services, and changes in the Medicare Physician Fee Schedule (PFS) can have significant implications for clinical Diagnostic Labs. In 2018, several policy changes were implemented in the Medicare PFS that directly impacted clinical Diagnostic Labs. Let's explore these specific policy changes and their implications for the lab industry.
Introduction to the Medicare Physician Fee Schedule
The Medicare Physician Fee Schedule (PFS) is a list of payment rates for services furnished by physicians and other Healthcare Providers to Medicare beneficiaries. It sets the Reimbursement rates for various healthcare services, including laboratory tests and procedures. The Centers for Medicare & Medicaid Services (CMS) updates the PFS annually to reflect changes in medical practice, technology, and other factors.
Policy Changes in the 2018 Medicare Physician Fee Schedule
1. Changes to Payment Rates for Clinical Laboratory Tests
One of the significant policy changes in the 2018 Medicare Physician Fee Schedule was the implementation of new payment rates for clinical laboratory tests. CMS revised the payment rates for laboratory tests based on the recommendations of the Clinical Laboratory Fee Schedule (CLFS) Advisory Panel. The goal was to align payment rates with the actual cost of performing the tests and ensure fair Reimbursement for laboratory services.
Under the new payment rates, some laboratory tests saw an increase in Reimbursement, while others experienced a decrease. Labs that performed tests with reduced payment rates were particularly affected, as they had to adjust their billing practices and financial strategies to compensate for the decrease in revenue.
2. Changes to the Appropriate Use Criteria (AUC) Program
CMS also introduced changes to the Appropriate Use Criteria (AUC) program for advanced diagnostic imaging services in 2018. The AUC program aims to promote the appropriate use of imaging services by requiring physicians to consult clinical decision support mechanisms before ordering certain advanced imaging tests for Medicare patients.
Starting in 2018, CMS began the implementation of the AUC program on a voluntary basis, allowing clinicians to participate in the program without facing payment penalties. The program was phased in gradually, with full implementation scheduled for 2020. Clinical Diagnostic Labs that provided imaging services were affected by these changes, as they had to comply with the AUC program requirements and ensure that referring physicians followed the guidelines for ordering imaging tests.
3. New Payment Policies for Molecular Pathology Tests
CMS also introduced new payment policies for molecular pathology tests in the 2018 Medicare Physician Fee Schedule. These tests play a crucial role in diagnosing genetic disorders, cancer, and other diseases, and their Reimbursement rates have been a point of contention in the laboratory industry.
Under the new payment policies, CMS aimed to address concerns about overutilization and potential fraud in billing for molecular pathology tests. The agency introduced new reporting requirements for labs performing these tests and established clearer guidelines for billing and coding molecular pathology services. Labs had to adapt to these changes and ensure compliance with the new policies to receive Reimbursement for molecular pathology tests.
4. Changes to Part B Drug Payment Policies
In addition to changes in laboratory payment rates, CMS implemented new policies for Part B drug payments in the 2018 Medicare Physician Fee Schedule. These policies affected clinical Diagnostic Labs that bill for drugs administered to patients during laboratory procedures, such as chemotherapy drugs or contrast agents used in imaging tests.
Changes to Part B drug payment policies included updates to the Average Sales Price (ASP) payment methodology, drug pricing formulas, and Reimbursement rates for Part B drugs. Labs had to navigate these changes and ensure accurate billing for drugs administered to Medicare beneficiaries while maintaining compliance with CMS guidelines.
Considerations for Clinical Diagnostic Labs
The policy changes in the 2018 Medicare Physician Fee Schedule had significant implications for clinical Diagnostic Labs, requiring them to adapt to new payment rates, reporting requirements, and compliance guidelines. Labs that were affected by these changes had to assess the impact on their operations, billing practices, and financial outlook. Here are some considerations for clinical Diagnostic Labs in light of the policy changes:
- Monitoring Payment Rates: Labs should monitor changes in payment rates for laboratory tests and adjust their billing practices accordingly to ensure accurate Reimbursement.
- Compliance with Reporting Requirements: Labs performing molecular pathology tests or other specialized services should ensure compliance with reporting requirements and coding guidelines to avoid payment delays or denials.
- Participation in AUC Program: Labs providing imaging services should consider participating in the Appropriate Use Criteria (AUC) program and assisting referring physicians in following the guidelines for ordering imaging tests.
- Adapting to New Policies: Labs should stay informed about updates to Part B drug payment policies and drug pricing formulas to maintain compliance with CMS Regulations.
Conclusion
The policy changes in the 2018 Medicare Physician Fee Schedule had a significant impact on clinical Diagnostic Labs in the United States. Labs had to navigate changes in payment rates, reporting requirements, and compliance guidelines to maintain their financial viability and provide high-quality services to patients. By staying informed about these policy changes and adapting their practices accordingly, clinical Diagnostic Labs can continue to play a crucial role in advancing healthcare through accurate and timely diagnostic testing.
Disclaimer: The content provided on this blog is for informational purposes only, reflecting the personal opinions and insights of the author(s) on phlebotomy practices and healthcare. The information provided should not be used for diagnosing or treating a health problem or disease, and those seeking personal medical advice should consult with a licensed physician. Always seek the advice of your doctor or other qualified health provider regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. If you think you may have a medical emergency, call 911 or go to the nearest emergency room immediately. No physician-patient relationship is created by this web site or its use. No contributors to this web site make any representations, express or implied, with respect to the information provided herein or to its use. While we strive to share accurate and up-to-date information, we cannot guarantee the completeness, reliability, or accuracy of the content. The blog may also include links to external websites and resources for the convenience of our readers. Please note that linking to other sites does not imply endorsement of their content, practices, or services by us. Readers should use their discretion and judgment while exploring any external links and resources mentioned on this blog.