TAG:
Fee-for-service
Fee-for-service has long been the primary payment model for clinical laboratories and pathology groups. Fee-for-service (FFS) is a payment model in which services are paid for as itemized in the provider’s invoice. It gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care. Similarly, patients are incentivized to welcome any medical service that might not be necessary. Insurance companies shield themselves against ruin by setting cover limits for every beneficiary.
FFS raises costs, discourages the efficiencies of integrated care, and a variety of reform efforts have been attempted, recommended, or initiated to reduce its influence (such as moving towards bundled payments and capitation).
Medicare Parts A (hospital insurance) and B (optional insurance that covers physician, outpatient hospital, home health, laboratory tests, durable medical equipment, designated therapy, outpatient prescription drugs, and other services not covered by Part A) are FFS programs. Medicare processes over one billion FFS claims per year.
As part of the ongoing drive to cut healthcare costs, this model is gradually being phased out by payers and healthcare organizations in favor of value-based payment models, such as pay-for-performance programs and accountable care organizations that are intended to cap costs and spread financial risk among providers, while encouraging coordination of care, disease prevention and better management of chronic conditions. This is seen as a threat to the survival of clinical labs, which expect to see far fewer tests ordered by healthcare providers.
The Clinical Laboratory Management Association is working to help labs navigate these changes. “As fee-for-service reimbursement gives way to bundled reimbursement and per-member-per-month payment, labs will only be successful if they add value to physicians by helping them diagnose disease earlier and more accurately,” says CLMA President Paul Epner.
CLMA has named this program “Increasing Clinical Effectiveness,” or ICE. THE DARK REPORT is one of CLMA’s partners in this effort.
“Our hope is that ICE is a catalyst that helps lab administrators, pathologists, and medical laboratory scientists broaden the focus of their laboratory beyond operational efficiency to include measurable impact on positive patient outcomes,” says Epner.
Did Qui Tam Suit Trigger Medi-Cal Price Concerns?
CEO SUMMARY: It is easy to track backwards to understand why the California Department of Healthcare Services (DHCS) began aggressive enforcement of its interpretation of statute 51501(a) against a number of labs this summer. DHCS officials were given a full education and a roadm…
FTC Opposes LabCorp’s Acquisition of Westcliff
CEO SUMMARY: On November 30, FTC commissioners filed an administrative complaint opposing Laboratory Corporation of America’s acquisition of Westcliff Medical Laboratories, Inc., on the grounds that it “violates antitrust laws and would lead to higher prices and lower quality…
Systems Approach For Pre-Authorization Of Genetic Tests
CEO Summary: Pre-authorization of expensive genetic and molecular tests is a threat to local clinical laboratories and pathology groups if payers exclude them from provider networks in favor of labs which bid the lowest prices. But one major healthcare corporation believes there …
Payers Move to Pre-Authorize Expensive Genetic Tests
CEO Summary: Pre-authorization of expensive genetic and molecular tests is fast-becoming a priority for most of the nation’s health insurers. For clinical labs and pathology groups that don’t respond, this trend is a threat. On the other hand, because payers need all the skil…
California’s Legal Challenge to Discount Pricing
PROBABLY NO TOPIC IN THE LAB TESTING INDUSTRY generates more controversy than discounted pricing for physicians, managed care companies, and IPAs (independent physician associations). Almost every pathologist and laboratory executive decries the corrosive effects of below-cost pricing. Yet, many of …
Did Wrong Strategy Sink Westcliff Medical Labs?
CEO SUMMARY: All sorts of people will argue all sorts of opinions about the financial demise of BioLabs, Inc., and its subsidiary, Westcliff Medical Laboratories, Inc., and why it ended up in a California bankruptcy court. Documents filed in the case indicate that, from the birth…
Rate of Health Spend Increase in 2008 Was Lowest Since 1960
RECENTLY the Centers for Medicare and Medicaid Services (CMS) reported on healthcare spending for 2008. The noteworthy finding was that the rate of increase in health spending fell to 4.4% for 2008. This is the lowest annual rate of increase in health spending since CMS first began …
Plain Talk about Current “Health Reform” Effort
CEO SUMMARY: It appears that a determined effort to reshape and restructure the entire American healthcare system is unfolding in Congress. Missing in public discourse about this vital topic is informed, intelligent discussion about the types of alternative healthcare de…
Attorney General Brown Sues Seven California Labs
CEO SUMMARY: California Attorney General Jerry Brown made a big splash last month by accusing seven lab firms of committing “massive fraud and kickbacks” under state Medicaid laws. However, he is relying on a legal theory that has not prevailed in some prior court cases invol…
Is CMS Playing “Bait and Switch” in San Diego?
ATTEMPTING TO WRITE THE ASSESSMENT of the Medicare Clinical Lab Services Competitive Demonstration Project that you will read in this issue earned a unique distinction: since our founding in 1995, this has been the sin…
CURRENT ISSUE
Volume XXXII, No. 6 – April 21, 2025
Now that a federal judge has vacated the FDA’s LDT rule, The Dark Report analyzes the judgement and notes the various steps the FDA could take in response. Also, lab testing at pharmacies is proving to be less successful than was once anticipated.
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