S 2761HR 5269119th CongressIn Committee

RESULTS Act

Introduced: Sep 10, 2025

Sponsor: Sen. Tillis, Thomas [R-NC] (R-North Carolina)

Economy & Taxes

Chamber Versions:

Standard Summary

Comprehensive overview in 1-2 paragraphs

The Reforming and Enhancing Sustainable Updates to Laboratory Testing Services Act of 2025 (the RESULTS Act) would overhaul how Medicare sets private-payor–based payment rates for clinical diagnostic laboratory tests under Part B. It creates a new, independent data infrastructure to gather private payor rates and volumes for widely available non-ADLT tests (and, separately, data for ADLTs). Using this data, the bill would base Medicare’s “final payment rate” on market-based information (primarily the private payor payments reflected in a qualifying comprehensive claims database) rather than relying on current, potentially opaque internal payment updates. The aim is to provide long-term stability and transparency for Medicare beneficiaries’ access to lab testing, while reducing rate instability and improving data quality. The bill also includes default payment rules if data are missing, moves toward public explanations of payment calculations, tightens data-reporting rules, and adjusts certain rate-reduction mechanisms and sunset provisions. In short, the RESULTS Act would (1) create a national, independent data source for private-payor lab payments, (2) shift Medicare payment rates toward a market-based, data-driven methodology with “final payment rates,” (3) establish clear data collection periods and rules, (4) require public disclosure of how rates are calculated, and (5) adjust timing, scope, and limits on rate reductions and reviews to ensure more predictable coverage for lab tests over time.

Key Points

1Data infrastructure for market-based payments
2- Establishes a qualifying independent claims data entity (a national nonprofit not affiliated with government or health-sector entities) to collect and maintain a qualifying comprehensive claims database.
3- The database must include at least 50 billion private payor claims from many payors, meet privacy/security requirements (HIPAA), and apply quality assurance and version control.
4- The Secretary is required to contract with such an entity to obtain applicable information for widely available non-ADLT tests.
5Definitions and scope
6- Creates precise definitions for terms such as:
7- Widely available non-ADLT clinical diagnostic laboratory test (not an ADLT and with broad provider availability).
8- ADLT (advanced diagnostic laboratory tests).
9- Qualifying independent claims data entity and qualifying comprehensive claims database.
10- Distinguishes data for widely available non-ADLT tests from non-widely available non-ADLT tests and ADLTs.
11Payment rate calculations and data use
12- For widely available non-ADLT tests, Medicare payments would be based on the final payment rate derived from private-payor data, including the volume paid by each payor in the collection year.
13- Final payment rate definitions and data elements (including the notion of rate plus volume by payor) are added, and the weighted median approach is refined to incorporate data from the independent data entity for 2028 and later.
14- The policy introduces a “final payment rate” concept and requires use of such data for determining Medicare payments for these tests.
15Default payments and data gaps
16- If there is no contract with a qualifying independent claims data entity or there is no applicable information, a default payment mechanism applies.
17- For widely available non-ADLT tests with no data, payment would equal the previous year’s payment adjusted by the Consumer Price Index (CPI) increases during a defined qualified-rate period.
18- For non-widely available non-ADLT tests without applicable information, a process (cross-walking to the most appropriate test or using a gap-filling method) determines payment, with the option to use a gap-filling approach if no match exists.
19Public explanation and rulemaking
20- Requires the Secretary to publish an explanation of payment rates, including supporting data, so laboratories can assess calculation accuracy.
21- Mandates rulemaking to define data-collection parameters for data-collection periods beginning after 2027.
22Data collection periods and market-based data updates
23- Data collection periods shift to begin in 2027 and 2028 under new definitions, with 6-month periods for post-2027 data collection.
24- For data collection periods beginning after January 1, 2027, “final payment rate” is defined and used to evaluate data from the private-payor database.
25- Excludes Medicaid managed care organization data from market-based rate calculations for data collection periods before 2028.
26Limits on payment reductions and sunset reviews
27- Reforms or stretches the schedule of payment reductions, moving away from earlier fixed reductions toward a 5% reduction cap in 2029 and beyond (instead of 15% reductions in earlier years).
28- Adds a sunset/review requirement (due before January 1, 2029) to assess the data-driven approach and market-based updates.

Impact Areas

Primary group/area affected- Medicare beneficiaries who rely on clinical diagnostic laboratory tests (non-ADLT and ADLT) for evaluation and management.- Independent labs and other providers of lab testing (as payment rates and data transparency affect reimbursements).Secondary group/area affected- Private payors, laboratory benefit managers, and provider networks, whose private-payor rates feed into the data used to set Medicare payment rates.- Public labs and hospital labs that bill under Part B for diagnostic tests.Additional impacts- Potential changes in access to non-ADLT tests if the market-based rate system stabilizes or shifts relative to current payor mix.- Increased transparency around how lab payment rates are calculated (public explanation requirement) and the data used to determine rates.- Administrative and implementation considerations, including contracting with an independent claims data entity, ensuring privacy/security of data, and updating CMS data systems and payment rules.- The exclusion of Medicaid MCO data from market-based rate calculations prior to 2028 could affect the representativeness of rate-setting data but is intended to focus on broader private-payor market signals.Sponsor: Senate leaders Tillis and Warnock; status is Introduced in the 119th Congress (as of the provided text).The bill focuses specifically on laboratory testing services and the way Medicare uses private-payor data to set rates, with extensive changes to data collection, definitions, rate calculations, and transparency mechanisms. It does not appear to alter other Medicare fee schedules outside of laboratory tests, beyond the adjustments to data periods and rate-setting methods described.

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