Medicare laboratory payment policy : now and in the future / Dianne Miller Wolman, Andrea L. Kalfoglou and Lauren LeRoy, editors.

Format:

• Book

Contributor:

• Wolman, Dianne Miller.
• Kalfoglou, Andrea L.
• LeRoy, Lauren.
• Institute of Medicine (U.S.). Committee on Medicare Payment Methodology for Clinical Laboratory Services.

Language:

English

Subjects (All):

• Hospitals--Outpatient services--Prospective payment--United States.
• Medicare.
• Diagnosis, Laboratory--United States.

Physical Description:

1 online resource (261 p.)

Edition:

1st ed.

Place of Publication:

Washington, D.C. ; [Great Britain] : National Academy Press, c2000.

Language Note:

English

Summary:

Clinical laboratory tests play an integral role in helping physicians diagnose and treat patients. New developments in laboratory technology offer the prospect of improvements in diagnosis and care, but will place an increased burden on the payment system. Medicare, the federal program providing coverage of health-care services for the elderly and disabled, is the largest payer of clinical laboratory services. Originally designed in the early 1980s, Medicare's payment policy methodology for outpatient laboratory services has not evolved to take into account technology, market, and regulatory changes, and is now outdated. This report examines the current Medicare payment methodology for outpatient clinical laboratory services in the context of environmental and technological trends, evaluates payment policy alternatives, and makes recommendations to improve the system.

Contents:

• Medicare Laboratory Payment Policy
• Copyright
• REVIEWERS
• Preface
• Acknowledgments
• Contents
• Summary
• INTRODUCTION
• THE LABORATORY INDUSTRY
• THE CURRENT MEDICARE PAYMENT SYSTEM
• GOALS FOR A PAYMENT SYSTEM
• ASSESSMENT OF THE CURRENT MEDICARE PAYMENT SYSTEM
• RECOMMENDATIONS
• CONCLUSION
• REFERENCES
• 1 Introduction
• ORIGINS OF THIS STUDY
• STATEMENT OF TASK
• THE IOM STUDY PROCESS
• CLINICAL LABORATORY SERVICES COVERED BY MEDICARE
• THE MEDICARE PROGRAM
• What Types of Laboratory Services Are Included in the Medicare Laboratory Fee Schedule?
• ORGANIZATION OF THE REPORT
• 2 Background and Environmental Trends
• BACKGROUND ON THE CLINICAL LABORATORY INDUSTRY
• Sites of Service
• Geographic Distribution
• Size and Distribution of the Market
• Trends in Expenditures for Laboratory Services
• Financial Strength of the Laboratory Industry
• MEDICARE PART B CLINICAL LABORATORY TRENDS
• Medicare Part B Spending
• ENVIRONMENTAL TRENDS
• Regulatory Trends
• Clinical Laboratory Improvement Amendments of 1988
• Test Complexity and Laboratory Certification
• CLIA's Impact on the Laboratory Industry
• CLIA's Impact on Quality
• Occupational Safety and Health Administration
• MINIMIZING FRAUD, WASTE, AND ABUSE
• Stark Amendments
• OIG Investigations
• Medical Necessity Review
• PAYMENT TRENDS
• Medicare Shift to Prospective Payment Systems
• Growth of Managed Care
• RESPONSE FROM THE INDUSTRY TO ENVIRONMENTAL TRENDS
• Market Consolidation and Network Development
• Growth of Hospital-Based Laboratory Outreach Programs
• SUMMARY
• 3 Technology Trends in the Clinical Laboratory Industry
• AUTOMATION
• Preanalytic Stage
• Analytic Stage
• Postanalytic Stage
• INFORMATION TECHNOLOGY
• LABORATORY MEASUREMENT AND TESTING TECHNOLOGY.
• Esoteric Tests
• Genetic Testing
• Pharmacogenomics
• Nanotechnology
• TECHNOLOGY'S EFFECT ON SITE OF SERVICE
• Point-of-Care Testing
• Home Testing
• EFFECT ON CLINICAL LABORATORY STAFF REQUIREMENTS
• 4 Description of the Current Medicare Payment System and Its Historical Roots
• THE FDA APPROVAL PROCESS
• CODING POLICY
• Coding Updates
• Panel Codes
• Codes for New Technology
• Ambiguities in Code Use
• CLAIMS PROCESSING
• MEDICARE COVERAGE POLICY
• National Coverage Decisions
• Local Medical Review Policy
• Claims Denials
• Advanced Beneficiary Notice
• Negotiated Rulemaking
• MEDICARE PAYMENT POLICY
• Early History of the Payment System
• DEVELOPMENT OF THE CURRENT SYSTEM
• ELEMENTS OF A PAYMENT SYSTEM
• Type of Payment
• Unit of Payment
• Basis of Payment
• Level of Payment
• Panel Tests
• Congressionally Set Test Payment Levels
• Fee Level for New Technology
• Updating Payments
• Adjustments
• Geographic Adjustment
• Sole Community Hospital Adjustment
• Base-Fee Adjustment
• Inherent Reasonableness
• Cost Sharing
• EFFECT OF LABORATORY SPENDING ON PHYSICIAN PAYMENT
• 5 The Current System: How Well Does It Work?
• BENEFICIARY ACCESS
• FLEXIBILITY
• TRANSPARENCY
• VALUE
• ADMINISTRATIVE SIMPLICITY AND EFFICIENCY
• OTHER ISSUES OF CONCERN
• Improving the Quality and Appropriate Use of Laboratory Services
• Coding Process for Outpatient Laboratory Tests
• Fraud, Waste, and Abuse
• 6 Alternative Payment Methodologies
• Definition
• Discussion
• Comparative Assessment
• Discussion.
• OTHER ISSUES IN PAYMENT SYSTEMS
• MAKING IMPROVEMENTS A REALITY
• Designing Payment Policies
• Implementing New Payment Policies
• 7 Recommendations
• Acronyms and Glossary
• ACRONYMS
• GLOSSARY
• APPENDIX A Acknowledgments
• APPENDIX B Medicare Clinical Laboratory Payments: The National Limitation Amount and Its Relationship to Payment Amounts
• APPENDIX C Study of Fees and Payment System Characteristics for Clinical Laboratory Services
• EXECUTIVE SUMMARY
• Study Methodology
• Study Findings
• STUDY OBJECTIVES AND DESCRIPTION OF STUDY METHODOLOGY
• Background and Study Objectives
• Payment Rate Determination Methodology
• Selection of Payers
• Selection of Clinical Laboratory Services
• Additional Information Included in the Survey
• CLINICAL LABORATORY PAYMENT RATES
• Introduction
• Clinical Laboratory Fee Data
• Clinical Laboratory Capitation Data
• Comparison of Fees
• CHARACTERISTICS OF LABORATORY SERVICE PAYMENT SYSTEMS
• Survey Approach
• Laboratory Payment System Characteristics
• EXHIBIT C.1: SURVEY INSTRUMENT FOR STUDY OF PAYMENT RATES FOR LABORATORY SERVICES
• Section I. Background and General Description of Laboratory Payment Methodologies
• Section II. Fee-for-Service Plans
• Section III. Capitated Plans
• Section IV. Additional Comments
• APPENDIX D Annual Volume of Laboratory Tests by Laboratory Type and Waived-Nonwaived Test Status, 1996-1998, 1999-Early 2000
• APPENDIX E 1998 Medicare Carrier Denial Rates
• APPENDIX F Committee Biographies.

Notes:

• Bibliographic Level Mode of Issuance: Monograph
• Includes bibliographical references.

ISBN:

• 9786610185221
• 9780309183611
• 0309183618
• 9781280185229
• 1280185228
• 9780309564984
• 0309564980

OCLC:

70773713