RESULTS Act

This bill amends the Social Security Act to improve how Medicare sets payment rates for clinical diagnostic laboratory tests by using private payor data, aiming for more accurate and sustainable rates. It introduces new data collection methods and adjusts payment rules for different types of tests.

Sec. 2, Improving accuracy and data collection for Medicare payment rates: For widely available non-advanced diagnostic lab tests (non-ADLTs), starting with data collection periods for reporting periods on or after January 1, 2028, the Secretary of Health and Human Services must collect applicable information from a qualifying comprehensive claims database of an independent national nonprofit entity, rather than relying solely on lab-reported data. The Secretary must contract with such an entity. The definition of 'applicable laboratory' changes for reporting periods beginning on or after January 1, 2028, to reference existing regulations. New definitions are added for 'non-widely available non-ADLT', 'qualifying independent claims data entity', 'qualifying comprehensive claims database', and 'widely available non-ADLT' (tests with over 100 providers/suppliers receiving payments in the first 6 months of the prior year). Data collection periods for non-advanced tests after the initial 2028 period will be the 6-month period starting January 1 of the year before the reporting period. The bill also updates data collection periods and rulemaking deadlines.

Sec. 2(b), Incorporating data collection improvements into payment rates: For widely available non-ADLTs, the weighted median calculation of private payor rates will use data from the qualifying database. If no contract or data exists for such a test, payment increases by the Consumer Price Index for All Urban Consumers (CPI-U) from the previous year. For non-widely available non-ADLTs with no reported data, payment is determined by cross-walking to a comparable test or using a gapfilling process. The Secretary must publicly explain payment rates for all tests under this section, including supporting data. A technical correction clarifies that market rates apply through the year following the data collection period.

Sec. 2(c), Additional improvements for updated market-based data: For data collection periods starting on or after January 1, 2027, 'applicable information' means the final payment rate (last payment made, excluding denied, appealed, erroneous, or recouped payments) and volume for each private payor. For widely available non-ADLTs, this is for the year of the data collection period; for other tests, it is for the data collection period itself. Medicaid managed care organizations are excluded from data collection for reporting periods beginning before January 1, 2028. Limits on payment reductions are modified: the 15% cap for 2026-2028 is replaced with a 5% cap for 2029 and subsequent years, and the cap applies to 2017 and each subsequent year. Review limitations under the law are sunsetted before January 1, 2029.