LEADER 08915nam 2201129 a 450 001 9910810847203321 005 20240417000956.0 010 $a0-309-18361-8 010 $a1-280-18522-8 010 $a9786610185221 010 $a0-309-56498-0 035 $a(CKB)110986584753224 035 $a(OCoLC)70773713 035 $a(CaPaEBR)ebrary10068522 035 $a(SSID)ssj0000281862 035 $a(PQKBManifestationID)11221709 035 $a(PQKBTitleCode)TC0000281862 035 $a(PQKBWorkID)10306803 035 $a(PQKB)11591469 035 $a(MiAaPQ)EBC3377274 035 $a(EXLCZ)99110986584753224 100 $a20150424d2000 uy| 0 101 0 $aeng 135 $aurcnu|||||||| 181 $ctxt 182 $cc 183 $acr 200 10$aMedicare Laboratory Payment Policy $eNow and in the Future 205 $a1st ed. 210 $aWashington, DC, USA $cNational Academies Press$d2000 210 $cNational Academies Press 215 $a1 online resource (261 p.) 300 $aBibliographic Level Mode of Issuance: Monograph 311 $a0-309-07266-2 327 $aMedicare 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. 327 $aEsoteric 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. 327 $aOTHER 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. 606 $aMEDICAL$2bisac 606 $aMedicaid & Medicare$2bisac 606 $aMedical care, Cost of$zUnited States 606 $aMedicare$xEvaluation 606 $aPathological laboratories$zUnited States$xProspective payment 606 $aMedicare 606 $aProspective Payment System 606 $aClinical Laboratory Techniques 606 $aInsurance, Health 606 $aMedical Assistance 606 $aReimbursement Mechanisms 606 $aInvestigative Techniques 606 $aLegislation as Topic 606 $aPublic Assistance 606 $aInsurance, Health, Reimbursement 606 $aInsurance 606 $aSocial Control, Formal 606 $aHealth Care Economics and Organizations 606 $aFinancing, Organized 606 $aFinancing, Government 606 $aEconomics 606 $aHealth Care 606 $aMedical Care Plans$2HILCC 606 $aPublic Health$2HILCC 606 $aHealth & Biological Sciences$2HILCC 615 7$aMEDICAL 615 7$aMedicaid & Medicare 615 0$aMedical care, Cost of 615 0$aMedicare$xEvaluation. 615 0$aPathological laboratories$xProspective payment. 615 2$aMedicare 615 2$aProspective Payment System 615 2$aClinical Laboratory Techniques 615 2$aInsurance, Health 615 2$aMedical Assistance 615 2$aReimbursement Mechanisms 615 2$aInvestigative Techniques 615 2$aLegislation as Topic 615 2$aPublic Assistance 615 2$aInsurance, Health, Reimbursement 615 2$aInsurance 615 2$aSocial Control, Formal 615 2$aHealth Care Economics and Organizations 615 2$aFinancing, Organized 615 2$aFinancing, Government 615 2$aEconomics 615 2$aHealth Care 615 7$aMedical Care Plans 615 7$aPublic Health 615 7$aHealth & Biological Sciences 700 $aDianne$b Miller Wolman$01669952 702 $aAndrea$b L. Kalfoglou 702 $aLeRoy$b Lauren 712 02$aInstitute of Medicine (U.S.).$bCommittee on Medicare Payment Methodology for Clinical Laboratory Services. 801 0$bPQKB 801 2$bAzTeS 906 $aBOOK 912 $a9910810847203321 996 $aMedicare Laboratory Payment Policy$94031473 997 $aUNINA