RESULTS Act
The RESULTS Act (Reforming and Enhancing Sustainable Updates to Laboratory Testing Services Act of 2025) would overhaul how Medicare sets payments for clinical diagnostic laboratory tests by anchoring those payments to more accurate, market-based private payer data. The core idea is to use data from a qualifying independent nonprofit claims data entity and its comprehensive database to determine private-pay rates and then reflect those rates in Medicare payment updates for widely available non-ADLT (non-advanced diagnostic laboratory test) tests. The bill creates a phased data-collection framework, defines new terms, requires public explanations of payment rates, and provides default mechanisms if data collection fails. Overall, it aims to provide longer-term stability and more accurate reimbursement for laboratory testing under Medicare, with a strong emphasis on transparency and market-based data. The bill builds a structured transition from pre-2027 approaches to a data-driven system starting in 2028 (with some 2027-activity and definitions). It also addresses gaps when data are unavailable (via a CPI-based fallback), expands data collection periods, and imposes sunset and review provisions. In short, Medicare would increasingly rely on private payer data to determine lab test payments and would require public accountability and updated data definitions to support that shift.
Key Points
- 1Data framework built around a qualifying independent claims data entity and a qualifying comprehensive claims database to collect and report private payer data for widely available non-ADLT lab tests; the Secretary must contract with such an entity and ensure privacy, quality controls, and representative data across all states.
- 2New definitions and data collection structure for after January 1, 2027: data collection periods, final payment rate, and treatment of widely available non-ADLT vs. other tests (e.g., ADLT) to ensure rates reflect actual private-pay amounts and volumes paid by different payors.
- 3Default payment mechanism when data are unavailable or a contract with a qualifying entity cannot be established: payments would be set to the previous year’s amount adjusted by the Consumer Price Index (CPI), with a defined “qualified rate period” that governs how long the fallback rate applies.
- 4Public explanation requirement: the Secretary must publicly explain the payment rate for each laboratory test, including supporting data needed for laboratories to assess the calculations’ accuracy.
- 5Data period updates and market-based focus: the bill shifts to data collection periods beginning in 2027-2028, requiring final payment rates and payer-specific volumes for those periods; it also excludes Medicaid managed care organization data from market-rate calculations before 2028 and updates how data collection periods are defined (including a 6-month period for certain future periods).