Medicare and Medicaid programs; reimbursement for clinical laboratory services: Health Care Financing Administration. Final rule with comment period.
These regulations implement section 918 of Public Law 96-499, the Omnibus Reconciliation Act of 1980, which establishes the payment criteria for laboratory services billed by physicians under the Medicare and Medicaid programs. Specifically, these amendments provide that: (1) laboratory tests performed by a physician, or personnel under his or her supervision, will be paid on the basis of the reasonable charge for the service (determined under the usual Medicare rules on reasonable charges); (2) laboratory tests performed by an independent laboratory, but billed by a physician who identifies the laboratory and the amount the laboratory charged him or her, will be paid on the basis of the lesser of (a) the laboratory's reasonable charge for the service, or (b) the amount the laboratory charged the physician for the service; and (3) if the physician does not identify the laboratory and the amount it charged him or her for the test, payment will be based on the lowest amount at which the Medicare carrier estimates the test could have been obtained by the physician from a laboratory serving the physician's locality. These rules should result in lower Medicare and Medicaid payments since they limit recognition of markups of bills from physicians for services performed by independent clinical laboratories and enable the programs to benefit from discontinued rates obtained by physicians.
D006761:Hospitals; D007348:Insurance, Health / Q000331:legislation & jurisprudence*; D007349:Insurance, Health, Reimbursement / Q000331:legislation & jurisprudence*; D007753:Laboratories / Q000191:economics*; D008484:Medicaid / Q000331:legislation & jurisprudence; D006278:Medicare / Q000331:legislation & jurisprudence; D010820:Physicians; D014481:United States