The RESULTS Act reforms Medicare's payment rate setting for clinical diagnostic laboratory tests by mandating the use of comprehensive, independently collected private insurance claims data starting in 2028 to ensure greater accuracy.
Thom Tillis
Senator
NC
The RESULTS Act of 2025 aims to significantly improve the accuracy of Medicare payment rates for common clinical diagnostic laboratory tests. It mandates that the Department of Health and Human Services (HHS) contract with an independent, certified entity to collect payment data from a massive, nationwide private insurance claims database. This shift ensures payment rates are based on comprehensive, validated external data rather than relying solely on self-reported information. If this external data is unavailable, default inflation-adjusted rates will apply until accurate data collection resumes.
Medicare Lab Test Payments Get a Major Data Overhaul: New System Relies on 50 Billion Private Claims Starting in 2028
The new Reforming and Enhancing Sustainable Updates to Laboratory Testing Services Act of 2025, or the RESULTS Act, is taking a massive swing at how Medicare pays for your basic lab work—think cholesterol panels or standard blood counts. Starting in 2028, the bill fundamentally changes the way Medicare sets payment rates for common, non-advanced clinical diagnostic lab tests. Instead of relying mostly on data self-reported by labs, the government wants to use a huge, independent database of private insurance claims to figure out the true median price (SEC. 2).
The Quest for 50 Billion Claims
Here’s the big shift: Medicare is required to contract with a national, nonprofit entity that maintains a "qualifying comprehensive claims database" (SEC. 2). This isn't just any database; it must contain at least 50 billion claims from over 50 different private insurers and be statistically representative of the entire country. Essentially, the government is outsourcing the data collection for what private insurers actually pay for these tests. The goal is to make Medicare’s rates more accurate and reflective of the real market, which should bring more stability to the system. For labs that conduct these common tests, this means their Medicare reimbursement rates will now be tied to a much broader, external benchmark, potentially smoothing out current payment volatility.
What Happens If the Data Fails?
This new system has a built-in safety net, which is smart. If, for some reason, the Secretary of HHS can’t secure a contract with a qualifying independent entity, or if the database lacks the necessary information for a specific test, the payment rate doesn't just vanish. Instead, the rate will default to the previous year’s rate plus an adjustment for inflation (using the Consumer Price Index for all urban consumers). This is a key protection, especially for smaller labs or those in rural areas, ensuring that a data hiccup doesn't immediately result in a financial crisis and that essential testing services remain available (SEC. 2).
Transparency and the Fine Print
The RESULTS Act also pushes for more transparency. Moving forward, HHS must publicly release a detailed explanation of how they arrived at the final payment rate for any lab test, including enough supporting data so that labs can actually check the math. This is a big win for accountability, allowing the industry to verify the accuracy of the calculations derived from that massive 50-billion-claim database. On the flip side, the bill also changes reporting deadlines and extends the required look-back period for data from three years to four years for certain future reporting cycles (SEC. 2). While the bill aims for accuracy, there is a sunset provision that limits the review of these payment rates after January 1, 2029, meaning the new methodology will be harder to challenge after that date.