Thursday, July 20, 2017

Brief Blog: What Medicare Paid HDL Lab, And How

This summer, I was describing to a client the "shell shock" that US payers experienced in 2013/2014 with an explosion of claims for cardiac biomarkers and pharmacogenetic testing.

In the case of cardiac biomarkers, this resulted in large Department of Justice settlements with labs in March 2015 (here).  As described in Forbes in April 2015, one lab rapidly skyrocketed to $400M revenue, $100M profit, but was bankrupt within a year (here).

Medicare has comprehensive online data for Part B payments from 2012-2015.   In CY2014, the Medicare MAC for Virginia paid $116M to HDL Laboratories (NPI 1629209853).  The top 20 codes garnered over 75% of the payments, click to enlarge:

About 25% of payments to this lab, totalling $30M, were for the nonspecific chromatography/mass spec codes 82541, '542, '545.  Some of these codes were deleted by 2016 (here).

Most tests were $15-50, the only outlier being 81225, CYP-P450, at $289.   Full data is available at the CMS 2014 database, here.

In CY2015, payments to this lab were still nearly $40M.   News stories evolved rapidly from the WSJ's first article in September 2014 (here) to discussion of the lab's bankruptcy filing in June 2015 (here).  See also a 2015 story at Dark Daily (here).

Today, both private payers like Aetna and Medicare payers like Noridian (MolDX) have much stricter controls against payment for cardiac biomarker tests (here, here).

Another lab that found itself in difficult times in the same 2014-2015 period was a New Orleans-based genetics lab (see NYT here); UTC Laboratories NPI 1720342884 did business as Renaissance Rx (here).  It appeared to do about $168M of business with one Medicare MAC in CY2014, based on data in the same CMS database.   For example, its billing of $34M for 81225 (CYP) was 32% of Medicare's nationwide CY2014 payments of $108M for that code.