Medicare Laboratory Payment Policy Now and in the Future (2000) / Chapter Skim
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Appendix C: Study of Fees and Payment System Characteristics for Clinical Laboratory Services
Appendix C: Study of Fees and Payment System Characteristics for Clinical Laboratory Services
Pages 184-214
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From page 184... ...
has been asked to conduct a survey of laboratory service payment rates used by different types of health care plans and to compare these payment rates to Medicare payment rates. This information should prove helpful to the IOM both in assessing the existing Medicare payment methodology and fees for clinical laboratory services and in evaluating alternatives for a new payment methodology.
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From page 185... ...
Included in the survey are laboratory services covered under the Medicare laboratory fee schedule as well as anatomic and surgical pathology services that are paid for by Medicare under its fee schedule for physician services. In addition to requesting data on fees for laboratory services, survey participants were asked to provide descriptions of the primary features of their laboratory payment methodologies as well as capitation rates used for laboratory services under managed care plans.
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From page 186... ...
As part of the IOM study, the Center for Health Policy Studies has been engaged to examine laboratory service payment rates used by different types of 3For three of the four health plans that use capitation, some laboratory services are not covered under the capitation rate.
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From page 187... ...
A mail and electronic survey with telephone follow-up was conducted of nine private payers that offer multiple types of health plans.4 The intent of the payment rate survey was to obtain clinical laboratory payment data for the following types of health benefit plans: . indemnify plane, PPO plans, POS plans, .
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From page 188... ...
The primary criteria were that payers surveyed should: . offer multiple types of health plans for which we could obtain laboratory fee data (e.g., indemnity, PPO, POS, and HMO plans)
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From page 189... ...
PPO plans represent the largest benefit plan type for Blue Cross/Blue Shield. This type of health benefit plan is more like the standard Medicare program than other types of private payer benefit plans for the following reasons.
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From page 190... ...
. These procedures are included in the study because it is of interest to determine if the relationship between private payer and Medicare fee levels is similar for laboratory services paid under the Medicare laboratory fee schedule and laboratory services paid under the Medicare RBRVS fee schedule.
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From page 191... ...
the administration's FY 2001 budget to have their national payment limit cut by 30 percent (CPT codes 83036, 84153, 84443, and 87086~. Additional Information Included in the Survey In addition to fees for specific clinical laboratory services, information relating to the primary characteristics of laboratory payment methodology was requested in the written survey or in follow-up questions addressed to survey respondents.
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From page 192... ...
Thus, ten payers provided fees from indemnity fee schedules, with one payer providing fees from different physician and independent laboratory fee schedules, for a total of eleven indemnity fee schedules.
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From page 193... ...
Thus, data from 14 PPO-POS fee schedules are provided in this report, from 10 PPO fee schedules, 3 POS fee schedules that differ from the PPO fee schedules, and 1 independent laboratory fee schedule that differs from the PPO fee schedule used to pay physicians for laboratory services. Clinical Laboratory Fee Data Laboratory procedure fee data are presented in most tables both in dollar values and as a proportion of the Medicare fee in the specific geographic area served by the health plan.
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From page 194... ...
For procedures covered under the Medicare fee schedule for physician services, the fee shown in the NLA column is the maximum Medicare fee among all of the localities represented by the survey health plans. The average ratio of the health plan fee to the Medicare fee in the health plan's service area is shown in the last column of Table C.4.
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From page 195... ...
This category of health plans represents the largest enrollment among the different types of health benefit plans, for both the United States as a whole and the health plans included in the CHPS survey. It is reported that for those enrolled under employee health benefit plans, 1998 PPO and POS plan enrollment was 98 million while HMO enrollment (not including POS plans)
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196 Go ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ o Cal CM ~ ~ ~ ~ ~ CM ~ ~ ~ ~ ~ ~ Do .
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From page 198... ...
Only four of the ten payers that participated in the survey provided fee data for Medicare HMO plans. Because of the limited number of fee schedules and also because one of the four health plans pays higher fees under its private and Medicare HMO plans than it does under its non-managed care plans, the average Medicare HMO to
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From page 202... ...
Clinical Laboratory Capitation Data The surveyed payers were asked to provide clinical laboratory service capitation payment data for their managed care plans in addition to fee data. Four of the ten payers that responded to the survey indicated that they use capitation for clinical laboratory services for at least one of their benefit plans.
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From page 203... ...
203 ._ Cal U
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i°There are three PPO and POS fee schedules in the two cities, resulting in 12 procedure fee comparisons.
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For most health plans, this information would be similar for all of their benefit plans that pay for laboratory services based on fee for service, specifically, their indemnity, POS, and to some extent, HMO plans. ~ The first row of Table C
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From page 206... ...
This health plan, which operates in a state that does not allow payment for laboratory tests to a provider that has not performed the test, is the only health plan that submitted separate independent laboratory fee schedule data. The lack of inclusion in the fee comparison tables of additional independent laboratory fee data for other health plans that use a separate laboratory fee schedule may result in an upward bias in the reported health plan fees.
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From page 207... ...
For most of these health plans, payments are based on a cost reimbursement formula, on discounted hospital charges, or on special fee arrangements negotiated with specific hospitals. The fee comparison tables (Tables C.4 C.8)
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From page 209... ...
Briefly describe the laboratory payment methodology used by each of your different types of benefit plans, e.g., indemnity, PPO, POS, HMO (private) , HMO (Medicare, Medicaid)
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From page 210... ...
Do capitation rates for the lab include specimen collection in the physician's office and other specimen handling services? Do capitation rates to the lab differ by age, sex, or other member characteristics?
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From page 211... ...
Provide fees for the following types of plans: Indemnity PPO POS HMO private (nongovernment patients) HMO Medicare HMO Medicaid If you use different fee schedules within one type of benefit plan (e.g., different fee schedules are used for two different HMO plans)
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From page 212... ...
Capitated Plans For health benefit plans for which laboratory capitation is used, please provide in Table B below, the monthly capitation rates (PMPM)
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From page 213... ...
Section IV. Additional Comments Please provide any additional information that you believe will be helpful in our understanding of your laboratory payment methodologies.
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