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ACLA: Low Reimbursement Jeopardizes Monkeypox Lab Testing Effort

by | Oct 19, 2022 | News, Open Content

Medicare Administrative Contractors are shortchanging labs on monkeypox test reimbursement, association says.

The American Clinical Laboratory Association (ACLA) warns that Medicare is shortchanging labs for monkeypox tests. And if labs are expected to continue to shoulder the financial burden, supplies and access to monkeypox tests will shrink.

While the US Centers for Disease Control and Prevention CDC developed the first PCR test to detect the virus in the early days of the outbreak, private labs are driving monkeypox test response, much as they did during the early days of the COVID-19 public health emergency. So far, the strategy has held up. The problem is that labs are being asked to subsidize the effort out of their own pockets.

The US Centers for Medicare & Medicaid Services (CMS) has said that Medicare would pay for the tests when a health professional orders them. However, rather than issue a national coverage determination (NCD), CMS has left it to the Medicare Administrative Contractors (MACs) to establish their own reimbursement rates for monkeypox tests. The ACLA contends that those MAC rates are alarmingly low. For example, Novitas, which manages two jurisdictions covering 11 states and the Veterans Affairs (VA) healthcare network, set reimbursement at just $51.31 per test; but that’s generous compared to the $35.09 that Noridian is paying to labs in California and the other 12 states it manages.

“Both of these rates do not align with ACLA’s recommendations and do not account for the inputs required to run a monkeypox test,” the ACLA wrote in its Aug. 19 letter to CMS administrator Chiquita Brooks-LaSure. “This raises significant concerns that an inadequate payment rate may impact patient access to testing for a pathogen that is currently declared a public health emergency in the United States.”

The ACLA called on CMS to set a national rate of $76.97, a figure it derived by applying a 1.5 multiplier to the Zika virus testing reimbursement rate while also factoring in the costs of personal protective equipment and other resources needed to provide monkeypox tests. The ACLA is also asking CMS to clarify Medicare and commercial insurance coverage rules so that labs can be assured that they’ll get paid before they invest in ramping up capacity for monkeypox testing. Without such certainty, they’re unlikely to make the commitment.

See the full article in our November 2022 Lab Industry Report.