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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.
Analyzing Lab Bid Demo To Predict Its Outcome
CEO SUMMARY: After two decades of study and preparation, the Centers for Medicare & Medicaid Services (CMS) is pushing the laboratory profession toward the first pilot site in the Congressionally-mandated Medicare Clinical Laboratory Services Competitive Demonstration Project. Designe…
Anticipate Access/Service Decline for S.D. Patients
CEO SUMMARY: In its primary push to use the Medicare Laboratory Competitive Bidding Demonstration Project as a tool to drive down the price Medicare pays for Part B laboratory testing services, CMS is giving secondary attention to patients’ needs. In particular, CMS seems to place littl…
Speculating On How Labs Might Respond to Demo
CEO SUMMARY: Statements and actions by CMS officials responsible for the laboratory competitive bidding demonstration project reveal the likelihood that they are using it as a Trojan Horse. While talking about implementation of a three-year demonstration project in the San Diego MSA, CMS …
Labs in U.S. and Australia Learn from Each Other
CEO SUMMARY: Australia just conducted its first summit meeting on laboratory management and a near sell-out crowd showed up to learn the best and latest. For the Americans in the audience, there were several surprises. First, Australia has a highly-competitive laboratory sector, comparabl…
A Pricing Strategy Soon to Boomerang?
HAVE NATIONAL LAB COMPANIES CREATED A REIMBURSEMENT BOOMERANG that will erode financial stability for the entire laboratory industry in the United States? I ask that question because the Medicare Competitive Bidding Demonstration Project for Laboratory Services has selected San Diego to be its first …
San Diego MSA Selected For Medicare Lab Demo
CEO SUMMARY: Earlier this month, CMS revealed its selection of the first of two sites for the Medicare Competitive Bidding Demonstration Project for Laboratory Testing Services. It will be the San Diego-Carlsbad-San Marcos MSA (metropolitan statistical area). An assessment of this MSA rev…
Will OIG Reconsider Policy on Discriminatory Pricing?
HEIGHTENED COMPETITION in recent months for exclusive managed care contracts between the two blood brothers may trigger the law of unintended consequences. One such consequence could be renewed interest by Medicare regulators in what they call “discriminatory billing.” “In 2003, the federal …
Labs Can Be Misguided by Pull-Through Test Myth
CEO SUMMARY: For the first time in almost eight years, there are major disruptions to the status quo in managed care contracting for laboratory testing services. As was true in the 1990s, national lab companies are pursuing exclusive national contracts with the nation’s…
JVHL Signs a Contract with UnitedHealth Group
CEO SUMMARY: When UnitedHealth Group announced its exclusive national contract with Laboratory Corporation of America, Joint Venture Hospital Laboratories (JVHL) saw opportunity. That’s because LabCorp does not have a significant presence in Michigan. JVHL parlayed its statewide network…
Office-Based Docs Want Anatomic Path Revenues
CEO SUMMARY: Specialist physicians think they’ve found gold in anatomic pathology services. Indifferent regions of the United States, urologists and gastroenterologists are taking active steps to cut themselves a piece from the anatomic pathology revenue pie. Some physician groups are b…
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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