RESULTS Act
The Reforming and Enhancing Sustainable Updates to Laboratory Testing Services Act of 2025, known as the RESULTS Act, would reform how Medicare sets private-payor-based payment rates for clinical diagnostic laboratory tests (CDLTs) under the Medicare program (Part B, title XVIII). The core idea is to build long-term stability and realism into Medicare payments by systematically collecting and using private payer rate data through a new, independent nonprofit data framework. Starting in 2027-2028, the Act would require data from a qualifying comprehensive claims database maintained by a qualifying independent claims data entity (an independent nonprofit with specific qualifications) to determine final payment rates for widely available CDLTs that are not advanced diagnostic laboratory tests (non-ADLTs). The bill creates detailed data-collection processes, defines what counts as applicable data, and establishes how payments should be updated when data are available or when data are missing. It also adds transparency (public explanations of payment rates) and sets sunset/renewal checks to review the approach. In short, the RESULTS Act aims to make Medicare CDLT payments more market-based, data-driven, and stable over time by expanding the data sources used to determine rates and clarifying how to proceed when data are incomplete.
Key Points
- 1Data framework and eligibility requirements: Establishes a new system in which a qualifying independent claims data entity maintains a qualifying comprehensive claims database and contracts with the Secretary to provide applicable information for widely available non-ADLT CDLTs. This database must pool data from many private payors, be representative across all states, and comply with privacy and quality standards.
- 2Definitions and scope: Distinguishes between widely available non-ADLT CDLTs, non-widely available non-ADLT CDLTs, and ADLTs, and creates specific definitions for data collection periods, final payment rates, and which tests are covered under the data framework. A widely available non-ADLT test is one with more than 100 providers receiving payments in the preceding year.
- 3Final payment rate and data incorporation: For data collection periods beginning in 2027 and beyond, final payment rates for widely available non-ADLT CDLTs will be based on the last paid amount for the test during the year (excluding denials, payments under appeal, or payments recouped by payors). Data from the qualifying comprehensive claims database will be used to derive these rates, along with annual volume data by payor.
- 4Default payments when data are missing: If the independent data contract or data are unavailable for a given test/period, the Act provides a default mechanism to determine payment—generally tying future payments to prior year levels adjusted by the Consumer Price Index. The timeline and method for applying these default rates are specified, including transitional “qualified rate periods.”
- 5Public explanation of payment rates: Requires the Secretary to publicly explain payment rates for CDLTs, including the data and methods used to calculate them, to enhance transparency for laboratories and payors.
- 6Data collection periods and updates: Reforms the timing and structure of data collection periods (including changing start dates and requiring semi-annual data collection periods moving forward), and defines how “final payment rate” data will be determined and used for subsequent years.
- 7Role of the independent nonprofit data entity: Sets criteria for what qualifies as a “qualifying independent claims data entity” and a “qualifying comprehensive claims database,” including nonprofit status, lack of government or industry affiliation, privacy compliance, and quality assurance processes.
- 8Sunset/oversight: Adds a sunsetting review requirement and a defined timeline for evaluating the data framework, with a view toward ongoing assessment of its effectiveness and need for renewal.