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November 14, 2018


ID Diagnostic Reimbursement Set to Take Another Hit

The Centers for Medicare and Medicaid Services (CMS) has issued the 2019 Physician Fee Schedule Final Rule, which contains final determinations for next year’s clinical laboratory fee schedule (CLFS). Following a 10 percent cut to reimbursement rates in 2018, infectious diseases diagnostic tests will get a second 10 percent reduction in 2019, with the possibility of a third 10 percent reduction in 2020. The rates are scheduled to take effect on Jan. 1, 2019.

IDSA and other physician organizations remain concerned that the myriad issues with CMS’ approach to data collection and analysis led to inappropriate new reimbursement rates for many tests, which will have a negative impact on patient access to testing. These rates do not reflect market-based payments as intended by Congress.

COLA, the largest accreditor of clinical laboratories in the country, surveyed clinical laboratories nationwide to better understand the impact of in-place cuts to the Medicare Clinical Laboratory Fee Schedule as well as the potential impact of upcoming cuts. The survey found that the upcoming cuts will make it more difficult for providers to offer clinical laboratory services in their practices. Over half of respondents also agreed that they would not be able to absorb an additional 10 percent cut in the Medicare laboratory fee schedule for 2019 and may stop offering testing services as a result.

IDSA submitted a letter to CMS Administrator Seema Verma outlining our concerns and recommendations regarding the 2019 CLFS and recent Medicare contractor determinations that will further decrease reimbursement for critical diagnostic tests. IDSA is making clear to policymakers that cuts reduce patient access to testing, thereby delaying diagnoses. Such delays can often have an extremely negative impact on patient outcomes and public health. Recommendations included:

  • Freeze upcoming cuts for two years while stakeholders work with CMS and Congress to develop a comprehensive solution to ensure that Medicare reimbursement truly reflects the market;
  • Address the flawed methodology for calculating fees on the CLFS, as the current method will reduce patient access to rapid, accurate testing and appropriate care in rural and underserved areas;
  • Utilize existing program integrity and program administration authorities to remedy data accuracy through a statistical survey method that is least burdensome on providers and reflects the full range of health care sites and their associated services and relative costs;
  • Expand Medicare’s determination of “medically necessary” services to include multiplex tests that are essential to rapid diagnosis for infectious diseases patient care. This will ultimately reduce test turnaround time, hospital stay length, disease transmission, and healthcare costs while enhancing the appropriate use of antibiotics that reduce antimicrobial resistance.

IDSA is drafting additional comments to CMS in response to the Physician Fee Schedule Final Rule and has been working with other concerned laboratorian- and clinician-focused organizations to educate Congress on the negative impacts of decreased reimbursement on patient care, public health, and diagnostics innovation. IDSA will continue to advocate for a reimbursement system that promotes innovative diagnostics and improves patient access as CMS moves forward in their efforts to reform clinical laboratory diagnostic reimbursement.

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