Tucked inside H.R. 4302, the Medicare Doc-Fix legislation signed by President Obama, is a new push by the government to collect from clinical diagnostic laboratories their private insurance payment rates for tests, so Medicare can use the data when establishing its own payment rates.

Sec. 216 of the bill authorizes the reporting of private insurance reimbursement rates for tests at clinical diagnostic labs beginning January 1, 2016, and every three years thereafter, except for “advanced” tests which would be reported annually. Payments made on a capitated or other similar payment basis, such as bundled payments, during the 12-month data collection period would be exempt from reporting.

Reported payment rates by laboratories would reflect all discounts, rebates, coupons and other price concessions. “In the case where an applicable laboratory has more than one payment rate for the same payer for the same test or more than one payment rate for different payers for the same test, the applicable laboratory shall report each such payment rate and the volume for the test at each such rate under this subsection,” according to the legislation. Beginning with January 1, 2019, the Department of Health and Human Services may establish rules to aggregate payment reporting of these types of tests.

Applicable laboratories failing to report private insurance payment rates would be subject to a fine of “up to $10,000 per day for each failure to report or each such misrepresentation or omission.” Payment information disclosed to HHS would remain confidential. Language in the bill requires HHS to establish rulemaking for data collection by June 30, 2015.

HHS further will require reporting of payment information for new FDA-approved tests that are not “advanced diagnostic laboratory tests” as they become available. These new tests would receive temporary HCPCS codes (Medicare billing codes) to identify them, which would be effective for up to two years until a permanent code is established.

Text of the legislation is available at congress.gov.


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