Fee-for-Service: Bridging the Knowledge Gap
Speaker:
Michael Astion, MD, PhD, Creator and Co-Founder, PLUGS, Seattle Children’s Hospital, Professor, Department of Laboratory Medicine and Pathology, University of Washington
Contact Hours:
1.0
Date:
January 23, 2025 - January 31, 2026
Description:
Fair payment for laboratory tests and protection for patients against excessive laboratory bills are both foundational to a lab's success. There is a surprising lack of general knowledge among laboratorians, from leaders through trainees, regarding the basic functioning and challenges of the fee-for-service system for test payment in the United States. This knowledge gap leads to a range of financial problems from low profitability to massive financial losses. In this lecture, the lab payment system is described including the coding and submission of an insurance claim; the administrative and medical necessity policies used by insurers (private or government) to accept or deny a claim, and the administrative rules determining the payment of claims by insurers and patients.
Learning Objectives:
- Describe the revenue cycle for fee-for-service laboratory testing.
- List several key elements of the insurance claim regarding appropriate payment for laboratory testing.
- Compare and contrast the perspective of patients, clinical laboratories, and insurers regarding the challenges of the fee-for-service payment system for lab tests.