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

• Record Nr.: UNINA9910810847203321
• Pubbl/distr/stampa: Washington, D.C. ; ; [Great Britain], : National Academy Press, c2000
• ISBN: 0-309-18361-8; 1-280-18522-8; 9786610185221; 0-309-56498-0
• Edizione: [1st ed.]
• Descrizione fisica: 1 online resource (261 p.)
• Altri autori (Persone): WolmanDianne Miller; KalfoglouAndrea L; LeRoyLauren
• Disciplina: 338.4336842600973
• Soggetti: Hospitals - Outpatient services - Prospective payment - United States; Medicare; Diagnosis, Laboratory - United States
• Lingua di pubblicazione: Inglese
• Formato: Materiale a stampa
• Livello bibliografico: Monografia
• Note generali: Bibliographic Level Mode of Issuance: Monograph
• Nota di bibliografia: Includes bibliographical references.
• Nota di contenuto: 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 -- GOALS FOR A PAYMENT SYSTEM -- 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 -- REFERENCES -- 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 -- REFERENCES -- 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 -- SUMMARY -- REFERENCES -- 4 Description of the Current Medicare Payment System and Its Historical Roots -- INTRODUCTION -- 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 -- CONCLUSION -- REFERENCES -- 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 -- CONCLUSION -- REFERENCES -- 6 Alternative Payment Methodologies -- INTRODUCTION -- ELEMENTS OF A PAYMENT SYSTEM -- Type of Payment -- Definition -- Discussion -- Comparative Assessment -- Unit of Payment -- Definition -- Discussion -- Comparative Assessment -- Basis of Payment -- Definition -- Discussion -- Level of Payment -- Definition -- Discussion.; OTHER ISSUES IN PAYMENT SYSTEMS -- Updating Payments -- Adjustments -- Cost Sharing -- MAKING IMPROVEMENTS A REALITY -- Designing Payment Policies -- Implementing New Payment Policies -- CONCLUSION -- REFERENCES -- 7 Recommendations -- INTRODUCTION -- CONCLUSION -- REFERENCES -- 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 -- REFERENCES -- 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.