Medicare Compliance & Reimbursement

Meanwhile, labs recruit docs to help oppose copays.

Though it's been three months since the House and Senate passed their respective versions of the "Prescription Drug and Medicare Act of 2003," the fate of laboratory copayments remains undecided.

The Senate's version of the Medicare bill (S. 1) calls for a 20-percent copayment from all Medicare beneficiaries receiving Part B clinical diagnostic laboratory tests and services. The introduction of lab copayments is intended to offset the costs of expanding rural health care coverage  - a plan that is much favored by Senate Finance Committee Chair Charles Grassley (R-IA).

However, should the copay provision make its way into the final bill, labs will be forced to chase down more than $18 billion in revenues from their patients over the next ten years.

While nearly 300 of the broad bill's provisions have been discussed by conferees' staffs already, neither the laboratory copayment nor rural health care provisions have been negotiated, reports Jason DuBois, manager of congressional and regulatory affairs for the American Society of Clinical Pathology in Washington.

DuBois states that earlier in the month, Grassley actually pulled his staff members out of the conference over concerns that many of the bill's big ticket items - including the rural health provision - were not yet being addressed. However, after several closed-door meetings with Rep. Bill Thomas (R-CA), Grassley sent his staff back into the conference, he says.

Given the pace and tenor of the bill negotiations, many Washington insiders speculate that a final agreement on the bill won't happen until mid-November at the earliest. DuBois believes that some of the bigger and more controversial provider issues - such as lab copays - will eventually be resolved by the conferees on a member-to-member level.

While the bill negotiations wage on, laboratorians are continuing to make their opposition to the copay provision known, says Jeffrey Boothe, an attorney with Holland & Knight in Washington who also serves as outside counsel to the Wayne, PA-based Clinical Labora-tory Management Association.

But even though lab groups are confident that they've got their message across to many sympathetic ears in Congress, they're not ready to declare victory yet. "At this point, we're acting like [the copay provision] is in unless we knock it out. So the industry is working very hard to try to knock it out," maintains Boothe.

One of the latest moves by the lab industry to increase awareness of the copay issue has been to recruit physicians to their cause. ASCP sent "a sign-on letter to physician groups highlighting the regulatory burden this would impose, the costs, and finally, the fraud and abuse implications for physicians" who engage in laboratory testing, says DuBois. For example, if the copayment provision were to pass, a physican office lab can't simply waive the copay since Medicare regulations require the POL to pursue the payment, he notes.

The letter, which was sent Aug. 25 to the Medicare conferees, states that the copay provision "would be extremely costly to seniors, while adding significant administrative and financial costs to physicians and laboratories when required to bill and collect copayments from patients."

The letter adds that "for the most frequently ordered tests the amounts to be collected are so small that they do not merit the cost of collection."

While industry groups continue their efforts to oppose lab copays, Boothe urges laboratorians and Medicare beneficiaries to keep up the pressure on the bill's committee members.

"There's going to be a recess period and members will probably be out in their home states during the first week in October," he says. "If the bill is not resolved by then, it provides another opportunity for folks to weigh and express their concerns."