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Medicare Part B
Medicare Part B medical insurance helps pay for some services and products not covered by Part A (hospital insurance) for Americans aged 65 and older who have worked and paid into the system. It also provides health insurance to younger people with disabilities.
Part B coverage begins once a patient meets his or her deductible ($147 in 2013), then typically Medicare covers 80% of approved services, while the remaining 20% is paid by the patient, either directly or indirectly by private Medigap insurance.
For clinical labs and pathology groups, Part B covers laboratory and diagnostic tests. Laboratory tests include certain blood tests, urinalysis, tests on tissue specimens, and some screening tests. They must be provided by a laboratory that meets Medicare requirements.
Complex rules are used to manage the benefit, and advisories are periodically issued which describe coverage criteria. On the national level these advisories are issued by CMS, and are known as National Coverage Determinations (NCD). Local Coverage Determinations (LCD) apply within the multi-state area managed by a specific regional Medicare Part B contractor, and Local Medical Review Policies (LMRP) were superseded by LCDs in 2003.
Medicare Part B payments make up about 15% of the revenue of the two biggest national lab companies. By contrast, it is common for community labs to have between 30% and 65% of their revenue come from Medicare Part B payments.
Part B coverage can also be provided by private insurers through Medicare Advantage Plans. Enrollment in private Medicare Advantage plans has more than doubled since 2006, according to the New York Times. As these plans gain popularity, clinical labs and pathology groups continue to find themselves without access to patients they once served. Medicare beneficiaries now enrolled in Advantage plans comprise nearly one-third of all Medicare beneficiaries.
Generally speaking, growth in Medicare Advantage enrollment favors the national labs, with private insurers providing them exclusive network contracts. This means less market access to these patients by community labs.
Preparing for the Medicare-Medicaid Buzz Saw
MEDICAID PROGRAMS IN TWO STATES ARE CURRENTLY TARGETING laboratory testing services as a source of cost savings. It’s not coincidental that the states involved are Florida and California. During the past 15 years, both states have stayed at the cutting edge of managed healthcare. Many “innovation…
Offering Molecular Tests Has Surprises & Pitfalls
CEO SUMMARY: Laboratories that offer some of the new assays based on molecular technologies often find themselves facing significant financial risk. That’s because payers are skeptical about new lab tests which come at a high price, but don’t offer substantial clinical benefit. One ea…
Supply and Demand for Lab Services and Pathologists
IT SEEMS THE LABORATORY INDUSTRY HAS MANAGED to beat back the proposed 20% patient co-payment for Medicare Part B laboratory testing services. Kudos to the hard-working laboratorians and their lobbyists who devoted money and time to oppose this proposal. But the news remains glum. Word is that lawma…
20% Medicare Co-Pay A Blow to Regional Labs
CEO SUMMARY: Informed speculation indicates that private health insurers are likely to adopt some form of laboratory test co-payment if the proposed Medicare 20% lab test co-pay legislation becomes law. For hospital laboratory outreach programs, the resulting reduction of reimbursement an…
Are Two Blood Brothers Using Economic Clout?
CEO SUMMARY: Quest Diagnostics Incorporated and Laboratory Corporation of America now dominate the national marketplace for testing referred by physicians’ offices. Release of their second quarter earnings reports provides the first look at their performance following the acquisitions i…
“June 16, 2003 Intelligence: Late Breaking Lab News”
Not all segments of the laboratory testing industry are pushing intensely to oppose an expected attempt to reintroduce legislation restoring the 20% patient co-payment for Medicare Part B lab testing services. (See …
Threat of Medicare 20% Co-pay for Lab Looms Again
BY NOW MOST OF YOU KNOW THAT THE LATEST ATTEMPT TO REINSTITUTE the 20% patient co-payment for Medicare Part B laboratory testing services was waved off in the Senate last week. But don’t relax, because similar proposals are expected to be put forward in Congress in coming months. It was a close c…
‘Health Lawyers News’ Attacks Pathology Part A
CEO SUMMARY: Pathologists should take time to read the cover story in the May 2003 issue of Health Lawyers News. Although the story nominally addresses questions involving how hospitals should reimburse physicians for administrative duties, it deals mostly with clinical pathology…
Aetna, AmeriPath, DIANON, IMPATH, JCAHO
AETNA RECOMMENDS PAYERS SUPPORT GENETIC SCREENING TESTS ALL LABORATORIANS SHOULD send a special note of thanks to Aetna Chairman and CEO John W. Rowe, M.D. for his recommendation that the health industry support the concept of genetic testing. He made these recommendations as part of speech…
Big Fight is Brewing Over Lab Test Reimbursement
BY NOW, MOST LAB EXECUTIVES AND PATHOLOGISTS AGREE that Medicare Part B fees and reimbursement guidelines for lab testing have just about become de facto national standards. That’s because private payers increasingly use Medicare as the basis for building their own pricing and reimbursement guideli…
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Economic, Tech changes drive lab concerns, The Dark Report provides insights from the Executive War College speakers about how clinical labs can use business strategies and tactics to handle the new tariffs, future regulations, and artificial intelligence (AI). Also, this issue provides guidance on how labs and pathologists should prepare for payer audits.
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