By Kimberly Scott, Managing Editor, G2 Intelligence
Industry stakeholders gathered in Baltimore July 14 to give officials at the Centers for Medicare and Medicaid Services (CMS) their recommendations on 2015 pricing for new and revised lab test codes, as well as payment methodology that will be use to revamp clinical lab pricing in future years.
There are more than 100 new and revised codes that will be on the 2015 Clinical Laboratory Fee Schedule (CLFS), many of them related to drug testing or genomic sequencing. Stakeholders, ranging from associations to labs to IVD companies, made recommendations to CMS on whether the new or revised codes should be gap-filled or cross-walked, and what existing codes would be most appropriate for cross-walking.
A few industry experts discussed methodologies for pricing new next-generation sequencing codes to be introduced in the 2015 CLFS. Commentary generally was focused on the complexity differences between panels (e.g., hotspot versus more comprehensive panels) and the resources that are involved in completing the assays. One speaker broke out the costs of performing a hotspot and non-hotspot panels (ranging from 5 to 50 genes), noting that hotspot panels are half the cost of more in-depth panels.
Participants also discussed the Protecting Access to Medicare Act of 2014 (PAMA), specifically the section titled "Improving Policies for Clinical Diagnostic Laboratory Tests." PAMA delays and provides limitations for implementation of annual CLFS cuts and ties Medicare reimbursement more closely to private payer reimbursement. The debate focused on managing what should be defined as an "applicable" lab (to keep representation broad while also keeping reporting and data requirements to a manageable level). Certain stakeholders suggested that if implemented as is, smaller labs would be at a disadvantage compared to larger labs because of economies of scale.
For more on the lab pricing meeting, see the next issue of National Intelligence Report.