Reimbursement System Fails Labs and Patients

There is confusion and disruption in the molecular testing sector of the clinical lab testing industry. That’s because both government and private payers were not ready to process and reimburse for the 100+ new molecular CPT test codes on January 1, 2013.

That is the date when the Medicare program was supposed to be ready to handle these molecular test claims. As a result, many clinical labs and pathology groups across the nation have now gone as long as three full months without payment for these claims.

This is a major failure of the system and a situation that is unique in my memory. I cannot recall a time over the past 20 years when government and private payers have ceased to pay labs for an important range of CPT codes for a period now extending to 14 weeks!

Equally significant is the fact that both laboratory executives and lab billing experts do not have a clear understanding of the scale and scope of this situation. There is a vacuum of knowledge about this topic.

In fact, as you read the comments from lab professionals we interviewed for this issue, you will see for yourself that most of what they have to share is anecdotal. It is a combination of personal experience, hearsay, and conjecture.

Yet, this issue of THE DARK REPORT is believed to be the most comprehensive coverage yet published about the failure of both government and private health programs to pay laboratories on a timely, accurate, and fair basis for those molecular test claims covered by the new molecular CPT codes. Once again, THE DARK REPORT has stepped up in a unique way to provide you with valuable business intelligence you can use to protect the clinical and financial integrity of your laboratory until this crisis passes.

I’d also like to offer you a piece of advice. There is no better time to contact your elected officials in Washington, DC, than now—a moment in time when the Department of Health and Human Services and the federal Centers for Medicare & Medicaid Services each cannot deny nor explain away the consequences of its failure to properly implement the new molecular CPT test codes. Your elected officials need to hear directly from you about the negative consequences to patient care and the destabilizing effects to the nation’s labs because of the bureaucracy’s gross mishandling of this situation.


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