Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
C L T
OMPARING  AB  EST 
 
 
P R :  M
AYMENT  ATES    EDICARE 
 
 
C A
OULD  CHIEVE 
S S  
UBSTANTIAL  AVINGS 
 
Daniel R. Levinson   
Inspector General  
 
June 2013 
OEI-07-11-00010   
   
EXECUTIVE SUMMARY - COMPARING LAB TEST PAYMENT RATES:  
MEDICARE COULD ACHIEVE SUBSTANTIAL SAVINGS 
OEI-07-11-00010 
 
 
WHY WE DID THIS STUDY 
 
Medicare is the largest payer of clinical laboratory (lab) services in the Nation.  It paid 
approximately $8.2 billion for lab tests in 2010, which accounted for 3 percent of all Medicare 
Part B payments. Prior to this evaluation, there had not been a comparison of Medicare 
payment rates to those of other health care service payers.  Such a comparison will help ensure 
that Medicare is a prudent purchaser of lab services.   
 
HOW WE DID THIS STUDY  
 
We collected payment data from 50 State Medicaid programs and 3 Federal Employees Health 
Benefits (FEHB) plans that pay for lab tests on a fee-for-service basis.  We requested the 
payment rates in effect from January 1 through March 31, 2011, for 20 lab tests.  For each lab 
test in each geographic area represented on the Medicare Clinical Laboratory Fee Schedule 
(CLFS), we compared Medicare paid claims  with the State Medicaid program fee schedule 
amount and FEHB plan median claim payment amounts.  We surveyed State Medicaid 
programs and FEHB plans to determine how their lab test fee schedules or payment rates were 
formulated, whether a copayment was charged to the patient, and whether lab test charges 
counted towards a members deductible.   
 
WHAT WE FOUND 
 
In 2011, Medicare paid between 18 and 30 percent more than other insurers for 
20 high-volume and/or high-expenditure lab tests.  Medicare could have saved $910 million, or 
38 percent, on these lab tests if it had paid providers at the lowest established rate in each 
geographic area. State Medicaid programs and 83 percent of FEHB plans use the Medicare 
CLFS as a basis for establishing their own fee schedules and payment rates, although most pay 
less. However, unlike Medicare, FEHB programs incorporate factors such as competitor 
information, changes in technology used in performing lab tests, and provider requests in their 
payment rates.  Some State Medicaid programs and FEHB plans required copayments for lab 
tests, which, in effect, lowered the costs of lab tests for the insurer.   
 
WHAT WE RECOMMEND 
 
We recommend that the Centers for Medicare & Medicaid Services (CMS) seek legislation that 
would allow it to establish lower payment rates for lab tests and consider seeking legislation to 
institute copayments and deductibles for lab tests.  In its comments, CMS stated that it is 
exploring whether it has authority under current statute to revise payments for lab tests 
consistent with OIGs recommendation and that a proposal to establish deductibles and 
coinsurance for lab tests is not included in the fiscal year 2014 Presidents Budget. 
   
   
   
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................4 

Findings........................................................................................................9 

In 2011, Medicare paid between 18 and 30 percent more for  

20 lab tests than other insurers.........................................................9 

Medicare could have saved $910 million in 2011 if it had paid  

the lowest insurers payment rate for 20 lab tests ..........................10 

Medicares payment rate methodology does not take into  
account technological and market changes ....................................10 

Unlike other insurers reviewed, Medicare does not require 

copayments and deductibles for lab tests .......................................11 
 
Conclusion and Recommendations ............................................................13 

Agency Comments and Office of Inspector General Response .....15 

Appendixes ................................................................................................16 

A: Lab Tests Included in Review ..................................................16 

B: Comparison of Medicare-Allowed Amounts for Lab Tests 

With Rates of Other Insurers .........................................................18 

C: Medicare Clinical Laboratory Fee Schedule, State Medicaid 

Program Fee Schedule, and Federal Employees Health Benefits 

Program Median Payment Rates for Selected Laboratory Test 

Codes..............................................................................................23 

D: Potential Savings to Medicare .................................................44 

E: Agency Comments  ...................................................................46 

Acknowledgments......................................................................................48 

 
 
   
   
OBJECTIVES 
To determine: 
1. 	  the extent to which 2011 Medicare payment rates for 20 selected 
laboratory (lab) tests vary from those of State Medicaid programs and 
Federal Employees Health Benefits (FEHB) plans, 
2. 	  the amount Medicare could have saved if it had paid a rate equal to the 
lowest insurers payment rate for the 20 selected lab tests,  
3. 	  how the methods for establishing Medicare lab test payment rates vary 
from those of State Medicaid programs and FEHB plans, and 
4. 	  the extent to which State Medicaid programs and FEHB plans require 
copayments and deductibles for lab tests. 
BACKGROUND 
Medicare is the largest payer of clinical lab services in the Nation.  It paid 
approximately $8.2 billion for lab tests in 2010, which accounted for 
3 percent of all Medicare Part B payments.1 Prior to this evaluation, there 
had not been a comparison of Medicare payment rates for clinical lab 
services with payment rates for other health care service payers.  Such a 
comparison will help ensure that Medicare is a prudent purchaser of lab 
services. Medicares methods for establishing payment rates for lab 
services have remained largely unchanged since 1984.   
Medicare Part B Coverage and Payment for Lab Tests  
Clinical diagnostic lab tests are performed on specimens taken from the 
human body.  Lab tests provide information integral to preventing, 
diagnosing, and treating disease. Most lab tests are conducted in hospital, 
physician-office, or independent laboratories.  Medicare Part B covers 
most lab tests and pays 100 percent of allowable charges; Medicare 
beneficiaries do not pay copayments or deductibles for lab tests.2    
Each lab submits claims to the Medicare Administrative Contractor 
(MAC) responsible for the area in which it is located.  Although 15 MACs 
have largely replaced Medicare Part B claims payment carriers (carriers)  
that corresponded closely to State borders, MACs continue to administer 
the same payment policies created by the former 57 carriers, as explained  
below.  
 
1 Centers for Medicare & Medicaid Services (CMS), Data Compendium:  Table II.3. 

Accessed at http://www.cms.gov/DataCompendium on June 8, 2012. 
 
2 Social Security Act (SSA),   1833(a)(1)(D) and (b)(3) and 1866(a)(2)(A). 
 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   1   
   
The Clinical Laboratory Fee Schedule 
Initial Establishment.   The Deficit Reduction Act of 1984 (DRA) 
mandated that payment rates be established for lab tests on a regional, 
statewide, or carrier basis.3   The DRA also mandated that the Consumer 
Price Index for All Urban Consumers (CPI-U) be used annually to adjust 
rates for inflation. Beginning July 1, 1984, each carrier established its 
own payment rates on the basis of prevailing charges for lab tests in its 
locality.  These payment rates are collectively known as the Clinical 
Laboratory Fee Schedule (CLFS). 
National Limitation Amount. The Consolidated Omnibus Budget 
Reconciliation Act of 1985 mandated a national limitation amount (NLA) 
for lab tests.4  Between July 1, 1986, and March 31, 1988, the NLA capped 
carrier rates at 115 percent of the median carrier rate for each lab test.5 For 
example, if the median carrier rate for a particular lab test was $100, the 
NLA capped carrier rates at $115.  Carriers could establish rates at or 
below the NLA, but could not exceed it.  
In an effort to contain costs, from 1988 through 1998, Congress 
incrementally lowered the NLA as a percentage of the national median 
carrier rate.6  Since 1998, the NLA has been set at 74 percent of the 
median carrier rate for each lab test.7  Under the CLFS, MACs pay 
laboratories the lower of the laboratories actual charges or the carrier rate  
as capped by the NLA.8  
CMS publishes an updated CLFS at least annually containing payment 
rates based on the 57 jurisdictions of the former carriers.9   The 2011 CLFS 
contains the median carrier rate, the NLA, and each carriers rate for 
1,140 unique lab tests identified by the Healthcare Common Procedure 
 
3  P.L. 98-369,  2303. 

4  P.L. 99-272,  9303(b). 

5  SSA,  1833(h)(4)(B)(i). 
 
6  SSA,  1833(h)(4)(B).  

7 SSA,   1833(h)(4)(B)(viii).  For new lab  tests for which  an NLA was not established 

before January 1, 2001, the NLA is set at 100  percent  of the median. 

8  SSA,  1833(a)(1)(D)(i). 
 
9 The 57 jurisdictions include the 50 States, the District of Columbia, and Puerto Rico.  

California, Kansas, and Missouri are each divided into  2 jurisdictions; New York is
  
divided into 3 jurisdictions. 
 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   2   
   
Coding System (HCPCS).10   As an example, HCPCS 82607 represents a 
lab test that checks the level of vitamin B-12 in blood.  The median carrier 
rate for this test is $28.66, and the NLA is 74 percent of this figure, or 
$21.21. The payment rate for 51 of the carrier jurisdictions is the NLA  
($21.21). The payment rates for the remaining six carrier jurisdictions are 
less than the NLA, ranging from $14.67 to $21.05.   
Adjustments to the CLFS.   Since the establishment of the CLFS, various 
laws have changed the calculation of the payment rates on the CLFS (see 
Table 1). 
Table 1:   Adjustments to CLFS Payment Rates for Lab Tests  
Year   Legislation   Effect on the CLFS  
Medicare Prescription 
Eliminated the CPI-U adjustments for 2004 through 2008; 
Drug, Improvement, and 
mandated that CMS implement a demonstration project to 
2003   Modernization Act of 2003, 
explore whether competitive bidding could reduce rates for 
P.L. 108-173,  628 and 
lab tests below  Medicares fee schedule rates.  
302(b) 
Medicare Improvements 
Repealed CMSs authority  for a competitive bidding 
for Patients and Providers 
2008   demonstration; lowered the CPI-U adjustment by  
Act of 2008, P.L. 110-275, 
0.5 percentage points from 2009 through 2013.  
 145(a) and (b)  
Repealed the 0.5-percentage point reduction in the CPI-U 
beginning in 2011 and replaced it with a reduction equal to 
Patient Protection and 
the 10-year moving average of annual multifactor 
2010   Affordable Care Act, 
productivity, which is determined by the Bureau of Labor 
P.L. 111-148,  3401(l)  
Statistics; reduced the CLFS by an additional 
1.75 percentage points in years 2011 through 2015. 
 
CMS has only limited authority to make adjustments to CLFS payment 
rates.11  Any additional changes to the CLFS require legislative action.  
Limits on Medicaid Payment for Lab Tests 
Section 1903(i)(7) of the SSA prohibits State Medicaid program payments 
for lab tests that exceed the Medicare payment amount.  Chapter 6, 
 
10 HCPCS Level 1 numerical codes are identical to CPT codes and are used by CMS 
when services  and procedures involve Medicare beneficiaries (e.g.,  70405).  The five  
character codes and descriptions included in this report are obtained from Current 
Procedural Terminology (CPT), copyright 2011 by the  American Medical 
Association (AMA).  CPT is developed by the AMA as a listing of descriptive terms  
and five character identifying codes and modifiers for reporting medical services 
and procedures.  Any use of CPT  outside of this report should refer to the most  
current version of the Current Procedural  Terminology available from 
AMA.   Applicable FARS/DFARS  apply.  
11  SSA  1833(h)(2)(A)(i) provides that the Secretary may  make adjustments to CLFS 
payment rates that are justified by technological changes.   SSA  1833(h)(2)(B) provides 
for adjustments or exceptions to the CLFS to assure adequate reimbursement of  
emergency laboratory tests needed for the provision of  bona fide emergency services and 
certain low-volume high-cost tests where highly sophisticated equipment or extremely 
skilled personnel are necessary to assure quality.  
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   3   
   
 6300.2, of the CMS State Medicaid Manual states that Medicaid 
reimbursement for clinical diagnostic lab tests may not exceed the amount 
that Medicare recognizes for such tests.  The section provides eight 
exceptions that pertain to lab tests furnished by certain types of facilities 
(e.g., hospices) and/or paid for under the end stage renal disease composite 
rate.  
FEHB Payment for Lab Tests 
FEHB plans contract with local plans and provider networks to provide 
services to members, including lab tests.  Within these contracts, FEHB 
plans negotiate payment rates.  Although Federal regulation limits the 
amount that providers may charge for inpatient hospital and physician 
services to the Medicare amount, no such limits exist for lab tests.12  
Related Reports 
A 2000 Institute of Medicine (IOM) report found that Medicares fee 
schedule for lab tests and its methodology for setting payment rates had 
not evolved to account for technological and market changes. IOM 
recommended that Medicare payments for lab tests be based on a single, 
rational, national fee schedule adjusted for geographic location to account 
for differences in costs of labor and supplies.13  
In 2009, the Office of Inspector General (OIG) found that 83 percent of 
carrier payment rates were at the NLA.14  OIG found that the variation in 
carrier payment rates did not appear to reflect geographic cost differences 
and that varying methods were used to update carrier payment rates.  OIG 
recommended that CMS seek legislation that would allow it to set accurate 
and reasonable payment rates for lab tests.  In its response, CMS noted 
that the Presidents budget for fiscal year 2010 did not include any 
proposals for amending the payment methodology for lab tests; therefore, 
CMS did not concur with this recommendation.  CMS further stated that it 
would consider the recommendation as it continued to monitor the effects 
of its payment policies.  CMS staff confirmed in early 2012 that it had no 
initiative underway to revamp the payment rate structure for lab tests.  
METHODOLOGY 
Scope 
We evaluated Medicare paid claims  for CLFS lab tests during 2011.  For 
CLFS lab tests, we included the top 15 lab tests by volume and by 
 
12 5 CFR  890.905. 
13 IOM,  Medicare Laboratory Payment Policy:  Now and in the Future, January 2000.  

Accessed at http://iom.edu/Reports/2000/ on June 8, 2012. 

14 OIG,  Variation in the Clinical Laboratory Fee Schedule, OEI-05-08-00400, July 2009. 
 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   4   
   
expenditure in 2010, the most recent data available at the time of our 
evaluation design. Because of overlap between these 2 groups of lab tests, 
a total of 20 tests were included in this evaluation.  These tests accounted 
for 47 percent of the volume and 56 percent of the expenditures for CLFS 
lab tests reimbursed by Medicare in 2010. 
To ensure equitable comparisons, we compared the Medicare CLFS 
payment rates only to those under State Medicaid and selected FEHB 
fee-for-service health care programs.  We did not compare Medicare 
fee-for-service payment rates to rates paid by managed care plans because 
managed care models typically involve an assumption of financial risk by 
providers. Also, our comparison of lab test prices used the fee schedule 
amounts for Medicaid programs and payment rates for FEHB plans.  The 
fee schedule amounts for Medicaid programs and payment rates for FEHB 
plans do not reflect copayments and deductibles because those are factored 
in only when claims are paid.   
Data Collection 
From  August through October 2011, we collected data from 50 State 
Medicaid programs and 3 fee-for-service FEHB plans.15  We requested the 
fee schedule amounts or payment rates in effect from January 1 through 
March 31, 2011, for 20 lab tests, as shown in Appendix A.  We surveyed 
State Medicaid programs and FEHB plans regarding how their lab test fee 
schedule or payment rates were formulated, whether a copayment was 
charged to the patient, and whether lab test charges counted towards a 
members deductible.   
We received fee schedule amounts and survey responses from all 50 State 
Medicaid programs.  State Medicaid programs provided their fee 
schedules for lab tests, representing the maximum payment rate allowed 
for each test.  (For actual claims, providers could have billed for less than  
the fee schedule amounts.) 
We received payment rates and survey responses from the three selected 
FEHB plans. These three plans provide coverage to 90 percent of 
fee-for-service enrollees in the FEHB program.  Each of these national 
plans provides services through local plans and networks.  Within a single 
national plan, local plans and networks may have differing payment rates.  
The FEHB plans provided us with first-quarter 2011 median claim  
payment amounts representing all of their local plans and networks by 
 
15 Staff from the Tennessee Medicaid program stated that 100 percent of recipients are 
enrolled in managed care plans; therefore, Tennessee does not  pay  for any lab tests on a 
fee-for-service basis.  We  did not  include the  Tennessee  Medicaid program  in our data  
collection. We included the District of Columbia, for a total of 50  State Medicaid  
programs. 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   5   
   
members States of residence.  However, they did not provide survey 
responses regarding how lab test payment rates were formulated for each 
individual plan or network.  In total, we received surveys from 29 of 
58 FEHB local plans and/or networks. 
Payment Rate Comparisons 
We used the population of Medicare claims for 20 lab test codes for tests 
performed in physician offices and independent laboratories during 2011.  
For each lab test in each geographic area, we compared the 
Medicare-allowed amount with the State Medicaid program fee schedule 
amount and each of the three FEHB plans median claim payment rates.16   
Insurers reported State-specific payment rates; therefore, we were able to 
make equitable comparisons across States.   
Our approach provides a conservative estimate of potential savings to the 
Medicare program because using Medicaid claim payment amounts or an 
FEHB plans lowest rate could produce greater differences in comparison 
to Medicare-allowed amounts. Table 2 summarizes the data sources used 
for the comparisons.  
Table 2: Data Sources Used in Payment Rate Comparisons  
Insurer  Data Source   Description  
CMS National Claims History  
Medicare  Allowed paid claims during 2011  
file  
Fee schedule amounts in effect during the first 
Medicaid  50 State Medicaid programs 
quarter of 2011  
Median allowed  payment rates for claims with 
All local plans and networks 
FEHB     dates of service during the first quarter 2011 for 
within three FEHB plans 
each of the three FEHB plans 
Source:  OIG data collection, 2012. 
 
We reviewed payment rates for 20 lab tests in each of 56 geographic 
jurisdictions for a total of 1,120 potential comparisons.17  However, not all 
insurers reported a payment rate for every lab test in each geographic 
jurisdiction; therefore, the Medicare-allowed amounts used in the 
comparisons vary by insurer.   Table 3 shows the number of tests for which 
insurers reported payment rates.   
 
16  We excluded  Medicare claims submitted by providers in geographic areas other than 
the 50 States and the District of Columbia.  To ensure equitable comparisons, we 
excluded claims paid  by the contractor that pays claims for the Railroad Retirement 
Board because this contractor pays claims  nationwide rather than in a specific geographic  
area.  
17 We did  not  include Puerto  Rico in our analysis; therefore, we compared payment rates 
in 56  of the 57  jurisdictions  represented on the Medicare CLFS. 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   6   
   
Table 3: Number of Lab Test Payment Rates Reported by Insurers and 
Medicare-Allowed Amount 
Number of Lab   2011 
Insurer  Test Payment  Medicare-Allowed 
Rates  Amount 
Medicaid  1,097   $2,355,233,694  
FEHB 1   1,054   $2,406,800,929  
FEHB 2   1,082   $2,410,847,338  
FEHB 3   1,119   $2,416,397,192  
Source:  OIG data collection, 2012. 
 
Savings Calculation 
We conducted a claim-by-claim analysis to calculate the potential savings 
to Medicare if it had paid providers at the lowest established rate in each 
geographic area for each of the 20 reviewed tests.  For example, the 
amount Medicare paid for an iron binding test (HCPCS code 83550) 
performed in Connecticut was compared with the fee schedule rate for the 
Connecticut Medicaid program and with the median allowed claim  
payment rate for each of three FEHB plans for members in Connecticut.   
Neither the Medicaid nor FEHB plan rates reflected copayments or 
deductibles because we were using Medicaid fee schedules and FEHB 
payment rates, not the amounts the program and plans actually paid for 
these tests. We subtracted the lowest available rate from the 
Medicare-allowed amount to calculate the potential savings to Medicare 
for that claim. Table 4 shows this calculation in detail.  
Table 4: Example Savings Calculation for an Iron Binding Test  
Lowest   Potential 
HCPCS  Payment 
Insurer  Available  Savings to 
Code   Rate 
Rate  Medicare 
Medicare  $12.30  
Medicaid  $11.60  
$12.30 minus $7.51 
83550   FEHB 1   $16.60   $7.51  
= $4.79  
FEHB 2   $12.28  
FEHB 3   $7.51  
Source:  OIG data collection, 2012. 
We summed the savings for each of the claims to calculate the total 
potential savings to Medicare. If the Medicare claim was paid at or below 
the lowest available rate, it was not included in the savings calculation.   
Limitations 
On the basis of the timing of our data collection, we collected fee schedule 
amounts and payment rates in effect for the period January 1 through 
March 31, 2011, from State Medicaid and FEHB programs.  We applied 
these payment rates to Medicare claims for all of 2011.  It is possible that 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   7   
   
State Medicaid or FEHB programs obtained different payment rates 
during April 1 through December 31, 2011, which would produce a 
different calculation of Medicare savings. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
   
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   8   
   
FINDINGS 
In 2011, Medicare paid between 18 and 30 percent 
more for 20 lab tests than other insurers 
We reviewed payment rates for 20 lab tests in each of 56 geographic 
jurisdictions.  Figure 1 shows the dollar amounts that Medicare paid for 
lab tests in 2011 compared with the dollar amounts that Medicare would 
have paid if it had paid at the rates that State Medicaid and FEHB plans 
paid for the same tests on the basis of their fee schedule amounts or 
payment rates. 
Figure 1: Comparison of Medicare-Allowed Amounts for Lab Tests With 
Rates of Other Insurers 
 
$2,500,000,000  $2.355  $2.407  $2.411  $2.416 
Billion  Billion  Billion  Billion 
 
 
$2.046 
$1.966  Billion 
  Billion 
$2,000,000,000  $1.854  $1.853 
 rs  Billion  Billion 
a
oll
 D Medicare-
d  Allowed Amount 
e
w
 o $1,500,000,000 
All Allowed Amount 
When Insurer 
  Had Lower Price 
Than Medicare 
 
  $1,000,000,000 
Medicaid  FEHB 1  FEHB 2  FEHB 3 
(20% More)  (18% More)  (30% More)  (30% More) 
 
Health Insurers 
 
Note:  Insurers  did not report payment rates for  all  lab tests in all jurisdictions; therefore, we could not make all 

 1,120  comparisons for each  insurer. 
 
Source:  OIG data collection, 2012. 

When we compared payment rates for specific tests in specific 
jurisdictions, the smallest price variation in which Medicare paid more 
than State Medicaid programs for lab tests was $0.01 (HCPCS 85025 in 
Montana) and the largest price variation was $34.98 (HCPCS 83970 in 
Kansas).  Among FEHB plans, the smallest price variation in which 
Medicare paid more was $0.01 (HCPCS 80048 in Tennessee) and the 
largest was $42.27 (HCPCS 83880 in Texas).  Appendix B, Tables B-1 
through B-4, provides more detail on the number of lab tests and allowed 
amount for each of the 20 reviewed tests for each insurer.  For a complete 
list of payment rates reported by health insurers for this evaluation, see 
Appendix C. 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)  9   
   
Medicare could have saved $910 million in 2011 if it 
had paid the lowest insurers payment rate for 20 lab 
tests 
Of the 4 insurers we reviewed, at least 1 paid a lower rate than Medicare 
on approximately 94 percent of the 1,120 price comparisons we 
performed.  Table 5 shows the distribution of lab tests paid by other 
insurers in relation to Medicare. 
Table 5: Lab Tests Paid by Other Insurers in Relation to Medicare 
Number and  Number and 
Number and  Number 
Percentage of  Percentage of 
Percentage of  of Tests 
Tests That  Tests That 
Insurer  Tests That  Not Paid 
Insurer Paid  Insurer Paid 
Insurer Paid at  by  
Above Medicare  Below Medicare 
Medicare Rates  Insurer 
Rates  Rates  
Medicaid  65  6%   95  9%   937  85%   23 
FEHB 1   402  38%   6  1%   646  61%   66 
FEHB 2   486  45%   1  <1%   595  55%   38 
FEHB 3   506  45%   9  1%   604  54%   1 
Note:  Insurers  did not report payment rates for  all  lab tests in all jurisdictions; therefore, we could not make all 1,120 

comparisons for each insurer. 
 
Source:  OIG data collection, 2012. 

 
If Medicare had paid providers for lab tests at the lowest established rates  
among the insurers we surveyed, it could have paid 38 percent less, saving 
$910 million.  For example, Medicare paid approximately $348 million for 
14.8 million commonly performed thyroid function tests (HCPCS Code 
84443) during 2011.  If Medicare had paid providers for these tests at the 
lowest established rate among the insurers we surveyed, it could have 
saved approximately $140 million, or 40 percent.18   Appendix D shows the 
potential savings that Medicare could achieve for each of the 20 tests 
reviewed using the lowest rate available.  
Medicares payment rate methodology does not take 
into account technological and market changes 
Medicares payment rates for lab tests were established in 1984 on the 
basis of prevailing charges for lab tests in each Medicare carrier 
jurisdiction.   Since that time, legislation has revised the rates by making 
uniform percentage adjustments to every test on the CLFS.  CMS has only 
 
18 Providers submitted, and Medicare paid, a rate lower than  the lowest established rate 
for approximately 296,000 tests. 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   10   
   
limited authority to make adjustments to CLFS payment rates.19   Any 
additional changes to the CLFS require legislative action. 
As the largest health insurer in the United States, Medicare has great 
influence on the actions of other health care insurers.  For example, 
Federal law prohibits State Medicaid program payments that exceed the 
Medicare payment amount for lab tests.20 Eighty-three percent 
(24 of 29) of responding local FEHB plans and networks reported that 
they use the Medicare CLFS as a basis for establishing their own fee 
schedules and payment rates.   
However, State Medicaid programs and local FEHB plans reported that 
they consider factors when establishing payment rates for lab tests that  
Medicare does not consider. For example, eight Medicaid plans and four 
local FEHB plans reported that technological changes (e.g., benchmarking 
payment rates for new tests to the actual cost of performing them) are 
taken into account when establishing payment rates.  Thirteen local FEHB 
plans reported taking into account market considerations, such as 
competitor information, membership size, and market analysis.  Other 
factors reported by State Medicaid programs and FEHB plans include 
provider requests to review the adequacy of a payment rate for a certain 
lab test and legislative and/or budgetary changes.   
Unlike other insurers reviewed, Medicare does not 
require copayments and deductibles for lab tests 
Beneficiaries enrolled in fee-for-service Medicare do not pay copayments 
for lab tests as they do for other Medicare Part B services (e.g., physician 
visits), nor are lab tests subject to a deductible.21  In comparison, 11 State 
Medicaid programs reported requiring copayments for lab tests in at least 
1 program or recipient category.22    
The amount of the copayment varied from 50 cents to $10; however,  
certain recipient categories were exempt from the copayment.  For 
example, the Colorado and Florida State Medicaid programs reported 
requiring a $1 copayment with exemptions for pregnant women and 
recipients living in nursing facilities.  In other States (e.g., Kentucky and 
Missouri), the copayment was inclusive of all services rendered by the 
same provider on a single date of service (e.g., a lab test and a doctors 
office visit).   
 
19  See note  11. 
 
20  SSA,  1903(i)(7). 

21  SSA,  1833(a)(1)(D)  and (b)(3)  and 1866(a)(2)(A). 

22 The 11  State Medicaid programs were Arkansas, Colorado, Florida, Iowa, Kentucky, 

Maine, Missouri, New Jersey, New York, South Dakota, and Wisconsin. 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   11   
   
Each of the three FEHB plans offered multiple coverage options for 
members, with varying copayment amounts among these options.  For 
example, one FEHB plans standard coverage option had a copayment 
of 15 percent of the providers allowed charges for lab tests, while another 
plans basic coverage option had no copayment.  For another FEHB 
plans high deductible coverage option, the copayment was a flat $15 
when the tests were not part of a doctors office visit.   
Two of the three FEHB plans had an option to avoid member copayments 
by offering lab cards, which are issued to members separately from the 
FEHB plans health insurance identification cards.  When members went 
to specified lab collection sites or requested that their physicians send their 
lab specimens to the specified laboratories, the members incurred no out-
of-pocket costs. When members chose to have their lab tests performed 
elsewhere, the tests were subject to copayments and deductibles.   
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   12   
   
CONCLUSION AND RECOMMENDATIONS 
In 2011, Medicare paid between 18 and 30 percent more for 20 lab tests 
than other insurers.  Medicare could have saved $910 million, or 38 
percent, in 2011 if it had paid the same rate as the lowest paying insurer 
surveyed for each lab test in each geographic location.  Achieving lower 
rates is possible because State Medicaid and FEHB lab test providers 
accepted these lower rates for lab tests. 
State Medicaid programs and FEHB plans use the Medicare CLFS as a 
basis for establishing their own fee schedules and payment rates, but most 
pay less. Unlike Medicare, FEHB programs incorporate factors such as 
competitor information, changes in technology used in performing lab 
tests, and provider requests. Some State Medicaid programs and FEHB 
plans required copayments for lab tests, which, in effect, lowered the costs 
of lab tests for the insurer.  
This report builds on previous OIG evaluations regarding lab test payment 
rates. A 2009 OIG report also recommended changes to the structure of 
lab test payment rates.  In that report, OIG found that 83 percent of carrier 
payment rates were at the NLA.  The  variation in carrier payment rates did 
not appear to reflect geographic cost differences, and varying methods 
were used to update carrier payment rates.  OIG recommended that CMS 
seek legislation that would allow it to set accurate and reasonable payment 
rates for lab tests.  At that time, CMS did not concur with this 
recommendation but stated that it would consider the recommendation as 
it continued to monitor the effects of its payment policies.  This report 
provides further evidence that the lab test payment rate structure is 
outdated and should be changed. 
We recommend that CMS: 
Seek Legislation That Would Allow CMS To Establish Lower 
Payment Rates for Lab Tests   
CMS could seek legislation that would provide for cost-saving measures 
such as: 
 
   conducting demonstration programs, such as competitive bidding 
(i.e., soliciting bids from lab test providers to obtain market rates) or 
entering into provider agreements (i.e., obtaining discounted rates 
from a small number of providers based on high lab test volume) and  
   including the ability to make adjustments to payment rates on an 
individual test basis to account for cost decreases due to technological 
changes and other factors. 
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Consider Seeking Legislation To Institute Copayments and 
Deductibles for Lab Tests  
Given that 11 State Medicaid programs and all three FEHB plans require 
copayments for lab tests in certain circumstances, CMS may want to 
consider whether copayments and deductibles for lab tests are appropriate 
for Medicare beneficiaries. We understand that Medicaid programs waive 
copayments for certain recipient categories and that two FEHB plans offer 
programs that motivate members to use certain lab test providers to avoid 
copayments.  The concept of beneficiary copayments and deductibles is 
used broadly for other types of services in Medicare; requiring them could 
lead to cost savings. 
   
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   14   
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS did not state whether it concurred or nonconcurred with OIGs 
recommendations.  Regarding the first recommendation, CMS stated that 
it is exploring whether it has authority under the current statute to revise 
payments for lab tests consistent with the recommendation.  Regarding the 
second recommendation, CMS stated that legislation would be required to 
establish deductibles and coinsurance for lab tests and that such a 
proposal is not included in the fiscal year 2014 Presidents Budget.  We  
ask that in its final management decision, CMS more clearly indicate 
whether it concurs with our recommendations and what steps, if any, it 
will take to implement them.   
We did not make any changes to the report based on CMSs comments. 
The full text of CMSs comments is provided in Appendix E.  
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   15   
   
APPENDIX A 
Lab Tests Included in Review  
Number  Percentage  Percentage  2011 
Total 
of  of All  of Total  Medicare 
Medicare-
HCPCS*   Medicare- Medicare- Medicare- National 
Description   Allowed 
Code23   Allowed  Allowed  Allowed  Limitation 
Amount in 
Tests in  Tests in  Amount in  Amount 
2010 
2010  2010  2010  per Test 
Metabolic panel, total 
80048   9,355,762  2.3%   $94,325,286  1.9%   $11.91  
calcium  
Comprehensive metabolic 
80053   27,232,042  6.6%   $319,935,253  6.5%   $14.87  
panel 
80061   Lipid panel  20,970,947  5.1%   $310,596,151  6.3%   $18.85  
Urinalysis, automated, 
81001   6,709,626  1.6%   $30,435,748  0.6%   $4.45  
with microscopy  
Urinalysis, nonautomated, 
81002   4,416,987  1.1%   $16,008,487  0.3%   $3.60  
without microscopy  
Urinalysis, automated, 
81003   4,805,501  1.2%   $15,435,365  0.3%   $3.16  
without microscopy  
82306   Vitamin D, 25 hydroxy  5,333,420   1.3%   $223,366,966   4.6%   $41.66  
82570   Assay of urine creatinine  4,362,909   1.1%   $32,023,975   0.7%   $7.28  
82607   Vitamin B-12  3,334,018  0.8%   $71,897,559  1.5%   $21.21  
82728   Assay of ferritin   4,361,621   1.1%   $84,963,813   1.7%   $19.17  
Glycosylated hemoglobin 
83036   12,652,264  3.0%   $175,307,639  3.6%   $13.66  
test 
83540   Assay of iron   5,455,091   1.3%   $49,960,956   1.0%   $9.12  
83550   Iron binding test   4,297,065   1.0%   $52,653,538   1.1%   $12.30  
83880   Natriuretic peptide  1,135,239  0.3%   $54,491,238  1.1%   $47.77  
83970   Assay  of parathormone   3,582,472  0.9%   $211,655,094  4.3%   $58.08  
*Healthcare Common Procedure Coding System.   continued on next page 
   
 
23  HCPCS Level 1 numerical codes are identical to CPT codes and are used by CMS 
when services  and procedures involve  Medicare beneficiaries (e.g.,  70405).  The five  
character codes and descriptions included in this report are obtained from Current 
Procedural Terminology (CPT), copyright 2011 by the  American Medical 
Association (AMA).  CPT is developed by the AMA as a listing of descriptive terms  
and five character identifying codes and modifiers for reporting medical services 
and procedures.  Any use of CPT  outside of this report should refer to the most  
current version of the Current Procedural  Terminology available from 
AMA.   Applicable FARS/DFARS  apply.  
 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   16   
   
Lab Tests Included in Review (Continued) 
Number  Percentage  Percentage  2011 
Total 
of  of All  of Total  Medicare 
Medicare- 
HCPCS   Medicare- Medicare- Medicare- National 
Description   Allowed 
Code   Allowed  Allowed  Allowed  Limitation 
Amount in 
Tests in  Tests in  Amount in  Amount 
2010  
2010  2010  2010  per Test 
Assay of prostate-specific 
84153   3,651,490  0.9%   $96,028,772  2.0%   $25.89  
antigen, total  
Thyroid stimulating 
84443   14,728,086  3.5%   $353,395,445  7.2%   $23.64  
hormone 
Complete blood count 
85025   with automated differential  31,930,801  7.7%   $351,630,565  7.2%   $10.94  
white blood cell count 
85610   Prothrombin time   22,020,091  5.3%   $123,445,269  2.5%   $5.53  
87086   Urine culture colony count   4,610,965   1.1%   $53,112,711   1.1%   $11.36 
     Total   194,946,397   47.0%   $2,720,669,830   55.5%   N/A  
Source:  Centers for Medicare & Medicaid Services National Claims History Part B Carrier File, 2012.   
   
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   17   
   
APPENDIX B 
Comparison of Medicare-Allowed Amounts for Lab Tests With 
Rates of Other Insurers 
Table B-1:  Comparison of Medicare-Allowed Amounts for Lab Tests With State 
Medicaid Program Rates  
Number 
Allowed  Percentage 
2011  2011  of Tests 
Amount If  Medicare 
HCPCS*  Number of   Medicare- With 
Description   Medicaid  Paid More 
Code24   Allowed  Allowed  Potential 
Lowest   Than 
Tests  Amount  for 
Rate Used   Medicaid 
Savings 
Metabolic panel, total 
80048   8,622,383    $85,612,322   5,668,213    $75,265,426    14%  
calcium  
Comprehensive 
80053   26,667,106    $308,060,147  13,365,771    $279,044,002   10%  
metabolic panel 
80061   Lipid panel  20,096,974   $293,294,006  9,799,707   $254,514,132   15%  
Urinalysis, automated, 
81001   6,636,868    $29,518,138   6,307,849    $25,392,723    16%  
with microscopy  
Urinalysis, 
81002   nonautomated,  4,153,597    $14,808,195   3,980,171    $11,481,389    29%  
without microscopy  
Urinalysis, automated, 
81003   4,808,096    $15,157,960   4,530,759    $12,590,841    20%  
without microscopy  
82306   Vitamin D, 25 hydroxy  5,308,512   $218,018,917  5,200,763   $173,834,730   25%  
Assay of urine 
82570   4,432,117    $31,958,084   4,274,416    $26,437,934    21%  
creatinine 
82607   Vitamin B-12  3,283,484   $69,600,580   3,208,218   $54,998,544    27%  
82728   Assay of ferritin   2,343,336   $44,791,773   2,285,840   $36,235,474    24%  
Glycosylated 
83036   12,374,324    $168,495,108  11,889,154    $139,534,720   21%  
hemoglobin test 
83540   Assay of iron   2,573,826   $22,783,202   2,416,826   $17,777,978    28%  
83550   Iron binding test   2,001,213   $24,090,743   1,952,675   $18,554,959    30%  
83880   Natriuretic peptide  982,145   $46,274,487   947,719    $38,836,439   19%  
Assay of 
83970   1,131,955    $65,699,438   1,103,363    $54,696,192    20%  
parathormone  
Assay of prostate-
84153   3,530,885    $91,280,209   3,415,111    $78,423,161    16%  
specific antigen, total 
*Healthcare Common Procedure Coding System.  continued on next page 
 
 
24  HCPCS Level 1 numerical codes are identical to CPT codes and are used by CMS 
when services  and procedures involve  Medicare beneficiaries (e.g.,  70405).  The five  
character codes and descriptions included in this report are obtained from Current 
Procedural Terminology (CPT), copyright 2011 by the  American Medical 
Association (AMA).  CPT is developed by the AMA as a listing of descriptive terms  
and five character identifying codes and modifiers for reporting medical services 
and procedures.  Any use of CPT  outside of this report should refer to the most  
current version of the Current Procedural  Terminology available from 
AMA.   Applicable FARS/DFARS  apply.  
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   18   
   
Table B-1:  Comparison of Medicare-Allowed Amounts for Lab Tests With State 
Medicaid Program Rates (Continued)  
Number 
Allowed  Percentage 
2011  2011  of Tests 
Amount If  Medicare 
HCPCS   Number of   Medicare- With 
Description   Medicaid  Paid More 
Code   Allowed  Allowed  Potential 
Lowest   Than 
Tests  Amount  for 
Rate Used   Medicaid 
Savings 
Thyroid stimulating 
84443   14,431,323    $340,218,728  13,470,738    $278,608,047   22%  
hormone 
Complete blood count 
with automated 
85025   29,982,902    $324,139,981  28,708,580    $256,024,097   27%  
differential white blood 
cell count  
85610   Prothrombin time   19,778,756   $109,118,351  18,595,275   $90,002,308    21%  
Urine culture colony  
87086   4,622,255    $52,313,325   4,523,417    $43,254,698    21% 
count 
    Total   177,762,057   $2,355,233,694   145,644,565   $1,965,507,794   20%  
Dollar amounts are  rounded to the nearest $1. 

Source:  Centers for Medicare & Medicaid Services (CMS), National Claims History Part B Carrier File, 2012.  

   
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Table B-2:  Comparison of Medicare-Allowed Amounts for Lab Tests With 
Federal Employees Health Benefits Plan  1 Rates  
Number 
Allowed  Percentage 
2011  2011  of Tests 
Amount If  Medicare 
HCPCS   Number of   Medicare- With 
Description   FEHB* 1  Paid More 
Code   Allowed  Allowed  Potential 
Lowest Rate   Than 
Tests  Amount  for 
Used  FEHB 1 
Savings 
Metabolic panel, total 
80048   8,845,138   $87,510,028   4,014,472   $79,233,694    10%  
calcium  
Comprehensive 
80053   27,383,560   $315,644,951  12,603,839   $285,465,515   11%  
metabolic panel 
80061   Lipid panel  20,582,622   $299,733,323  12,236,042   $264,780,532   13%  
Urinalysis, automated, 
81001   6,745,292   $29,999,388   5,393,503   $21,605,942    39%  
with microscopy  
Urinalysis, 
81002   nonautomated,  4,298,157   $15,328,388   858,224   $14,827,898    3%  
without microscopy  
Urinalysis, automated, 
81003   5,058,767   $15,955,168   3,097,997   $13,384,927    19%  
without microscopy  
82306   Vitamin D, 25 hydroxy  5,375,495   $220,809,451  4,791,414   $195,628,854   13%  
Assay of urine 
82570   4,599,040   $33,172,982   4,101,514   $28,388,052    17%  
creatinine 
82607   Vitamin B-12  3,348,724   $70,984,263   3,098,644   $57,669,263    23%  
82728   Assay of ferritin   2,390,169   $45,708,890   1,873,378   $38,683,459    18%  
Glycosylated 
83036   12,652,717   $172,332,541  11,637,788   $146,644,964   18%  
hemoglobin test 
83540   Assay of iron   2,610,331   $23,119,240   2,191,250   $19,978,006    16%  
83550   Iron binding test   2,029,047   $24,437,035   1,665,647   $20,793,342    18%  
83880   Natriuretic peptide  1,005,678   $47,600,430   616,946   $46,896,600    2%  
Assay of 
83970   1,144,866   $66,449,427   802,171   $57,235,817    16%  
parathormone  
Assay of prostate-
84153   3,610,064   $93,330,561   3,382,894   $69,756,354    34%  
specific antigen, total 
Thyroid stimulating 
84443   14,736,021   $347,421,480  11,997,260   $256,475,682   35%  
hormone 
Complete blood count 
with automated 
85025   30,778,859   $332,847,257  20,154,289   $277,782,489   20%  
differential white blood 
cell count  
85610   Prothrombin time   20,202,185   $111,459,803  11,817,701   $97,932,459    14%  
Urine culture colony  
87086   4,675,245   $52,956,323   249,964   $52,816,302    <1% 
count 
    Total   182,071,977   $2,406,800,929   116,584,937   $2,045,980,151   18%  
*Federal Employees Health Benefits Plan. 

Dollar amounts are  rounded to the nearest $1. 

Source:  CMS National Claims History Part B Carrier File, 2012. 

 
 
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Table B-3:  Comparison of Medicare-Allowed Amounts for Lab Tests With 
FEHB 2 Rates 
Number 
Allowed  Percentage 
2011  2011  of Tests 
Amount If  Medicare 
HCPCS   Number of   Medicare- With 
Description   FEHB 2  Paid More 
Code   Allowed  Allowed  Potential 
Lowest   Than 
Tests  Amount  for 
Rate Used   FEHB 2 
Savings 
Metabolic panel, total 
80048   8,868,300    $87,691,704   6,406,107    $56,925,617    54%  
calcium  
Comprehensive 
80053   27,406,336    $315,878,919  23,616,591    $190,298,975   66%  
metabolic panel 
80061   Lipid panel  20,620,917   $300,263,670  17,830,508   $181,050,752   66%  
Urinalysis, automated, 
81001   6,803,822    $30,259,846   5,013,009    $27,272,462    11%  
with microscopy  
Urinalysis, 
81002   nonautomated,  4,312,499    $15,380,015   801,000    $14,659,027    5%  
without microscopy  
Urinalysis, automated, 
81003   5,071,508    $15,995,094   2,423,151    $15,081,085    6%  
without microscopy  
82306   Vitamin D, 25 hydroxy  5,394,422   $221,597,882  1   $221,597,881   <1%  
Assay of urine 
82570   4,630,130    $33,399,315   234,400    $33,218,013    1%  
creatinine 
82607   Vitamin B-12  3,354,340   $71,103,569   2,647,056   $67,236,703    6%  
82728   Assay of ferritin   2,388,723   $45,681,170   2,215,722   $39,589,293    15%  
Glycosylated 
83036   12,678,817    $172,653,909  10,844,674    $158,505,857   9%  
hemoglobin test 
83540   Assay of iron   2,611,112   $23,123,274   2,377,920   $13,725,941    68%  
83550   Iron binding test   2,030,349   $24,449,112   1,606,576   $24,139,181    1%  
83880   Natriuretic peptide  1,003,642   $47,301,371   37,291   $47,200,413    <1%  
Assay of 
83970   1,140,880    $66,217,932   1,033,874    $52,503,547    26%  
parathormone  
Assay of prostate-
84153   3,616,338    $93,492,483   3,299,294    $75,992,390    23%  
specific antigen, total 
Thyroid stimulating 
84443   14,761,102    $348,014,395  13,578,188    $238,945,858   46%  
hormone 
Complete blood count 
with automated 
85025   30,827,609    $333,380,573  22,581,252    $240,858,678   38%  
differential white blood 
cell count  
85610   Prothrombin time   20,250,842   $111,728,873  9,901,125   $107,226,128   4%  
Urine culture colony  
87086   4,703,253    $53,234,232   4,376,383    $47,958,561    11% 
count 
    Total   182,474,941   $2,410,847,338   130,824,122   $1,853,986,362   30%  
Dollar amounts are  rounded to the nearest $1. 

Source:  CMS National Claims History Part B Carrier File, 2012.  

 
 
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Table B-4:  Comparison of Medicare-Allowed Amounts for Lab Tests With 
FEHB 3 Rates 
Number 
Allowed  Percentage 
2011  2011  of Tests 
Amount If  Medicare 
HCPCS   Number of   Medicare- With 
Description   FEHB 3  Paid More 
Code   Allowed  Allowed  Potential 
Lowest   Than 
Tests  Amount  for 
Rate Used   FEHB 3 
Savings 
Metabolic panel, total 
80048   8,870,790    $87,715,544   5,395,466    $67,285,713    30%  
calcium  
Comprehensive 
80053   27,406,336    $315,878,919  16,006,044    $255,119,055   24%  
metabolic panel 
80061   Lipid panel  20,620,917   $300,263,670  11,088,845   $250,104,002   20%  
Urinalysis, automated, 
81001   6,804,619    $30,263,393   4,301,384    $25,300,428    20%  
with microscopy  
Urinalysis, 
81002   nonautomated,  4,312,499    $15,380,015   2,843,481    $13,316,748    15%  
without microscopy  
Urinalysis, automated, 
81003   5,078,609    $16,012,775   3,061,511    $13,696,536    17%  
without microscopy  
82306   Vitamin D, 25 hydroxy  5,394,422   $221,597,882  4,916,470   $151,929,883   46%  
Assay of urine 
82570   4,649,643    $33,541,369   3,644,077    $25,746,329    30%  
creatinine 
82607   Vitamin B-12  3,363,543   $71,298,574   2,999,341   $50,209,954    42%  
82728   Assay of ferritin   2,401,360   $45,904,070   2,138,522   $32,616,087    41%  
Glycosylated 
83036   12,678,817    $172,653,909  9,693,743    $133,570,423   29%  
hemoglobin test 
83540   Assay of iron   2,625,017   $23,249,999   2,261,945   $16,042,910    45%  
83550   Iron binding test   2,043,113   $24,606,097   1,864,244   $17,182,469    43%  
83880   Natriuretic peptide  1,079,500   $50,924,545   929,185   $37,383,509    36%  
Assay of 
83970   1,154,873    $67,030,516   1,013,627    $47,853,311    40%  
parathormone  
Assay of prostate-
84153   3,616,338    $93,492,483   3,061,675    $68,755,732    36%  
specific antigen, total 
Thyroid stimulating 
84443   14,761,102    $348,014,395  12,759,702    $249,494,146   39%  
hormone 
Complete blood count 
with automated 
85025   30,827,609    $333,380,573  24,038,398    $258,080,023   29%  
differential white blood 
cell count  
85610   Prothrombin time   20,291,205   $111,952,080  12,595,842   $97,737,892    15%  
Urine culture colony  
87086   4,703,518    $53,236,384   4,222,236    $41,570,728    28% 
count 
    Total   182,683,830   $2,416,397,192   128,835,738   $1,852,995,878   30%  
Dollar amounts are  rounded to the nearest $1. 

Source:  CMS National Claims History Part B Carrier File, 2012.  

 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   22   
   
APPENDIX C 
Medicare Clinical Laboratory  Fee Schedule, State Medicaid 
Program Fee Schedule, and Federal Employees Health Benefits 
Program Median Payment Rates for Selected Laboratory Test 
Codes 
The following table contains the Medicare Clinical Laboratory Fee 
Schedule (CLFS) rates and the payment rates reported to us by State 
Medicaid programs and Federal Employees Health Benefits (FEHB) 
programs by Healthcare Common Procedure Coding System (HCPCS)25  
and geographic area.   
 
25  HCPCS Level 1 numerical codes are identical to CPT codes and are used by CMS 
when services  and procedures involve  Medicare beneficiaries (e.g.,  70405).  The five  
character codes and descriptions included in this report are obtained from Current 
Procedural Terminology (CPT), copyright 2011 by the  American Medical 
Association (AMA).  CPT is developed by the AMA as a listing of descriptive terms  
and five character identifying codes and modifiers for reporting medical services 
and procedures.  Any use of CPT  outside of this report should refer to the most  
current version of the Current Procedural  Terminology available from 
AMA.   Applicable FARS/DFARS  apply.  
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   23   
   
APPENDIX C 
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS  State 
Insurer 
Code   AK  AL  AR  AZ  CA 
Medicare  $11.91   $11.91   $11.91   $11.91   $11.91  
Medicaid  $12.12   $11.00   $12.09   $11.51   $9.27  
80048   FEHB 1   $7.10   $12.55   $18.40   $9.58   $9.58  
FEHB 2   $4.98   $15.97   $14.54   $4.98   $4.98  
FEHB 3   $11.00   $7.88   $15.09   $7.23   $10.28  
Medicare  $14.87   $14.87   $14.87   $14.87   $14.87  
Medicaid  $15.14   $12.00   $15.10   $14.38   $11.57  
80053   FEHB 1   $11.56   $14.00   $18.17   $11.56   $11.56  
FEHB 2   $6.19   $8.19   $19.32   $6.19   $6.19  
FEHB 3   $43.00   $9.84   $22.16   $9.03   $12.83  
Medicare  $18.85   $15.99   $17.89   $18.85   $18.85  
Medicaid  $19.19   $14.00   $18.16   $18.23   $13.74  
80061   FEHB 1   $13.69   $13.69   $21.85   $13.69   $13.18  
FEHB 2   $8.20   $8.20   $21.85   $8.20   $8.20  
FEHB 3   $65.00   $11.40   $26.66   $11.44   $16.25  
Medicare  $4.45   $4.45   $4.45   $4.45   $4.45  
Medicaid  $4.54   $4.00   $4.52   $4.31   $3.47  
81001   FEHB 1   $2.74   $2.74   $7.97   $2.74   $2.70  
FEHB 2   $5.54   $5.66   $6.65   $5.15   $3.80  
FEHB 3   $32.00   $5.50   $6.65   $2.71   $3.84  
Medicare  $3.60   $3.60   $3.60   $3.60   $3.60  
Medicaid  $3.66   $3.00   $3.66   $3.48   $2.80  
81002   FEHB 1   N/A  $7.00   $6.73   $3.75   $5.86  
FEHB 2   $5.61   $4.82   $4.39   $4.15   $6.00  
FEHB 3   $25.00   $4.50   $5.36   $3.43   $3.11  
Medicare  $3.16   $3.16   $3.16   $3.16   $3.16  
Medicaid  $3.22   $3.00   $3.20   $3.06   $2.46  
81003   FEHB 1   $5.21   $5.00   $5.65   $2.11   $2.19  
FEHB 2   $2.85   $4.24   $3.86   $2.85   $3.77  
FEHB 3   $29.00   $4.50   $4.71   $1.96   $2.73  
Medicare  $41.66   $41.66   $41.66   $32.59   $41.66  
Medicaid  $42.40   $29.00   $42.27   $31.51   $24.54  
82306   FEHB 1   $34.86   $43.88   $36.21   $36.21   $34.86  
FEHB 2   $57.73   $57.73   $57.73   $57.73   $57.73  
FEHB 3   $90.00   $33.92   $62.04   $19.77   $35.92  
Medicare  $7.28   $7.28   $7.28   $7.28   $7.28  
Medicaid  $7.41   $6.00   $7.39   $7.04   $5.27  
82570   FEHB 1   $5.79   $7.67   $6.68   $6.02   $6.02  
FEHB 2   $13.03   $8.02   $10.85   $10.13   $13.03  
FEHB 3   $26.87   $7.59   $10.85   $5.19   $6.28  
Medicare  $21.21   $21.21   $21.21   $21.21   $21.21  
Medicaid  $21.59   $17.00   $21.52   $20.51   $16.49  
82607   FEHB 1   $16.03   $22.34   $23.17   $16.65   $16.65  
FEHB 2   $19.71   $28.00   $27.13   $19.71   $19.71  
FEHB 3   $36.70   $17.27   $31.59   $12.75   $18.29  
Medicare  $19.17   $19.17   $19.17   $19.17   $19.17  
Medicaid  $19.51   $13.00   $19.46   $18.53   $14.91  
82728   FEHB 1   N/A  $20.19   $23.41   $15.61   $15.61  
FEHB 2   $16.38   $16.20   $23.41   $16.38   $16.38  
FEHB 3   $20.87   $15.61   $28.55   $11.63   $16.52  
Note:  N/A  indicates that  no  price  was reported for  the test.                                                                                           continued  on  next page 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   24   
   
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS   State 
Insurer 
Code   AK  AL  AR  AZ  CA 
Medicare  $13.66   $13.66   $13.66   $13.66   $13.66  
Medicaid  $13.90   $12.00   $13.87   $13.21   $10.63  
83036   FEHB 1   $11.45   $11.45   $14.92   $11.02   $11.24  
FEHB 2   $12.35   $14.67   $17.00   $12.35   $12.35  
FEHB 3   $61.50   $13.90   $20.34   $8.16   $11.78  
Medicare  $9.12   $9.12   $9.12   $9.12   $9.12  
Medicaid  $9.28   $7.00   $9.25   $8.82   $7.09  
83540   FEHB 1   $7.51   $7.80   $15.60   $7.51   $7.51  
FEHB 2   $5.12   $2.10   $11.14   $5.12   $5.12  
FEHB 3   $8.35   $5.57   $13.58   $5.53   $7.86  
Medicare  $12.30   $12.30   $12.30   $12.30   $9.85/$10.39*  
Medicaid  $12.52   $10.00   $12.48   $11.89   $7.88  
83550   FEHB 1   $9.57   $12.95   $18.36   $9.57   $9.57  
FEHB 2   $12.28   $9.45   $15.02   $12.28   $12.28  
FEHB 3   $14.65   $7.51   $18.32   $7.47   $8.97  
Medicare  $47.77   $47.77   $47.77   $47.77   $47.77  
Medicaid  $48.62   $33.00   $47.43   $46.19   $37.56  
83880   FEHB 1   N/A  $61.89   $66.40   $46.76   $47.65  
FEHB 2   $106.19   $150.60   $73.57   $122.25   $114.94  
FEHB 3   $40.44   $42.75   $17.60   $28.98   $41.19  
Medicare  $58.08   $58.08   $58.08   $58.08   $58.08  
Medicaid  $59.12   $51.00   $58.94   $56.16   $45.17  
83970   FEHB 1   N/A  $61.18   $80.88   $49.47   $86.27  
FEHB 2   $44.63   $78.68   $44.63   $44.63   $44.63  
FEHB 3   $49.16   $47.30   $86.51   $35.88   $50.09  
Medicare  $25.89   $25.89   $25.89   $25.89   $25.89  
Medicaid  $26.34   $20.00   $26.27   $25.02   $20.14  
84153   FEHB 1   $18.73   $21.85   $38.55   $18.73   $18.03  
FEHB 2   $20.48   $20.48   $28.79   $20.48   $20.48  
FEHB 3   $109.00   $19.76   $38.55   $15.70   $22.32  
Medicare  $23.64   $23.64   $23.64   $23.64   $23.64  
Medicaid  $24.06   $23.64   $23.98   $22.86   $18.38  
84443   FEHB 1   $16.16   $24.90   $26.47   $16.16   $16.16  
FEHB 2   $15.36   $15.36   $28.87   $15.36   $15.36  
FEHB 3   $45.00   $19.25   $35.21   $14.28   $20.39  
Medicare  $10.94   $10.94   $10.94   $9.03   $10.94  
Medicaid  $11.14   $10.00   $11.10   $8.73   $8.50  
85025   FEHB 1   $7.67   $11.52   $16.21   $7.67   $7.67  
FEHB 2   $10.86   $13.43   $14.00   $5.03   $5.03  
FEHB 3   $36.55   $13.00   $16.29   $5.48   $9.43  
Medicare  $5.53   $5.53   $5.53   $5.53   $5.53  
Medicaid  $5.62   $5.00   $5.61   $5.34   $4.30  
85610   FEHB 1   $4.38   $5.82   $8.24   $4.38   $4.38  
FEHB 2   $6.60   $7.00   $6.74   $5.12   $5.12  
FEHB 3   $35.00   $6.10   $8.24   $3.42   $4.77  
Medicare  $11.36   $11.36   $11.36   $11.36   $11.36  
Medicaid  $11.57   $10.00   $11.53   $10.99   $7.52  
87086   FEHB 1   N/A  $14.46   $20.68   $29.51   $24.50  
FEHB 2   $10.45   $10.45   $13.88   $10.45   $10.45  
FEHB 3   $37.00   $10.99   $16.92   $6.89   $9.80  
continued on next page 
* Four States (CA, KS, MO, and NY) are divided into multiple Medicare carrier jurisdictions.  Each jurisdiction may have a different price for 
some HCPCS codes.  In jurisdictions where prices  differ, differences are signified using / between each jurisdictions prices. 
 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   25   
   
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS   State 
Insurer 
Code   CO  CT  DC  DE  FL 
Medicare  $11.91   $11.91   $11.91   $11.91   $11.91  
Medicaid  $10.52   $11.24   $6.00   $11.67   $8.00  
80048   FEHB 1   $9.58   $15.84   $9.23   $9.23   $9.58  
FEHB 2   $4.98   $4.98   $5.92   $4.98   $4.98  
FEHB 3   $5.26   $7.27   $5.04   $7.08   $6.86  
Medicare  $14.87   $14.87   $14.87   $14.87   $14.87  
Medicaid  $13.14   $14.03   $12.00   $14.57   $10.00  
80053   FEHB 1   $11.12   $11.56   $11.12   $11.12   $11.56  
FEHB 2   $6.19   $6.19   $6.19   $6.19   $6.19  
FEHB 3   $6.61   $9.08   $5.31   $8.85   $8.57  
Medicare  $18.85   $18.85   $18.85   $18.85   $18.85  
Medicaid  $16.63   $17.78   $16.75   $18.47   $9.50  
80061   FEHB 1   $13.18   $13.18   $13.18   $13.18   $13.18  
FEHB 2   $8.20   $8.20   $8.20   $8.20   $8.20  
FEHB 3   $8.31   $11.51   $8.42   $10.90   $10.86  
Medicare  $4.45   $4.45   $4.45   $4.44   $4.45  
Medicaid  $3.93   $4.21   $2.00   $4.35   $3.27  
81001   FEHB 1   $2.74   $2.69   $2.66   $2.69   $2.74  
FEHB 2   $3.77   $3.80   $3.80   $3.80   $3.80  
FEHB 3   $2.04   $2.72   $1.99   $2.89   $2.57  
Medicare  $3.60   $3.60   $3.60   $3.60   $3.60  
Medicaid  $3.18   $3.39   $2.00   $3.53   $2.00  
81002   FEHB 1   $4.64   $5.36   $2.14   $2.68   $3.57  
FEHB 2   $2.14   $4.04   $2.24   $2.14   $3.93  
FEHB 3   $3.57   $2.97   $2.80   $2.80   $2.87  
Medicare  $3.16   $3.16   $3.16   $3.16   $3.16  
Medicaid  $2.79   $2.98   $1.00   N/A  $2.50  
81003   FEHB 1   $2.19   $4.23   $2.11   $3.14   $2.19  
FEHB 2   $1.97   $3.38   $2.67   $2.67   $2.85  
FEHB 3   $2.74   $2.61   $1.41   $2.09   $2.51  
Medicare  $41.66   $41.66   $41.66   $41.66   $41.66  
Medicaid  $36.76   $39.29   $20.00   $40.83   $30.00  
82306   FEHB 1   $34.86   $34.86   $34.86   $35.54   $34.86  
FEHB 2   $57.73   $57.73   $42.50   $57.73   $57.73  
FEHB 3   $18.49   $25.44   $18.61   $24.77   $23.99  
Medicare  $7.28   $7.28   $7.28   $7.28   $7.28  
Medicaid  $6.42   $6.87   $3.00   $7.13   $5.00  
82570   FEHB 1   $6.02   $6.02   $5.79   $6.50   $6.02  
FEHB 2   $13.03   $13.03   $9.07   $13.03   $13.03  
FEHB 3   $3.22   $5.10   $3.25   $5.19   $4.19  
Medicare  $21.21   $21.21   $21.21   $21.21   $21.21  
Medicaid  $18.72   $20.01   $10.00   $20.79   $15.00  
82607   FEHB 1   $16.65   $16.03   $16.03   $16.65   $16.03  
FEHB 2   $19.71   $19.71   $17.90   $19.71   $19.71  
FEHB 3   $9.33   $12.95   $9.48   $12.61   $12.21  
Medicare  $19.17   $19.17   $19.17   $19.17   $19.17  
Medicaid  $16.93   $18.08   $9.00   $18.79   $14.00  
82728   FEHB 1   $15.03   $15.32   $15.03   $15.03   $15.61  
FEHB 2   $16.38   $16.38   $16.18   $16.38   $16.38  
FEHB 3   $8.48   $11.71   $8.56   $11.40   $11.04  
continued on next page 
 
 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   26   
   
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS   State 
Insurer 
Code   CO  CT  DC  DE  FL 
Medicare  $13.66   $13.66   $13.66   $13.66   $13.66  
Medicaid  $12.07   $12.88   $8.80   $13.39   $9.50  
83036   FEHB 1   $11.02   $11.24   $11.02   $11.02   $11.02  
FEHB 2   $12.35   $12.35   $11.53   $12.35   $12.35  
FEHB 3   $6.11   $8.34   $6.10   $8.12   $7.86  
Medicare  $9.12   $9.12   $9.12   $9.12   $9.12  
Medicaid  $8.05   $8.60   $4.00   $8.94   $5.00  
83540   FEHB 1   $7.51   $7.51   $7.51   $7.51   $7.80  
FEHB 2   $5.12   $5.12   $4.53   $24.89   $5.12  
FEHB 3   $4.07   $5.57   $4.07   $6.50   $5.25  
Medicare  $12.30   $12.30   $12.30   $12.30   $12.30  
Medicaid  $10.86   $11.60   $12.00   $12.05   $8.50  
83550   FEHB 1   $9.57   $16.60   $9.57   $9.76   $9.95  
FEHB 2   $12.28   $12.28   $10.38   $39.87   $12.28  
FEHB 3   $5.43   $7.51   $5.49   $7.32   $7.08  
Medicare  $45.89   $47.77   $47.77   $47.77   $47.77  
Medicaid  $40.94   $45.06   $46.81   $46.81   N/A 
83880   FEHB 1   $47.65   N/A  $46.76   N/A  $45.87  
FEHB 2   $52.04   $142.00   $40.32   $40.32   $140.58  
FEHB 3   $31.99   $29.17   $26.34   $34.03   $42.75  
Medicare  $58.08   $58.08   $58.08   $58.08   $58.08  
Medicaid  $51.27   $54.79   $27.00   $56.92   $40.50  
83970   FEHB 1   $45.27   $365.90   $45.27   $46.15   $47.03  
FEHB 2   $44.63   $44.63   $49.02   N/A  $44.63  
FEHB 3   $25.61   $35.47   $31.72   $34.54   $33.45  
Medicare  $25.89   $25.89   $25.89   $25.89   $25.89  
Medicaid  $22.85   $24.42   $30.00   $25.37   $21.50  
84153   FEHB 1   $18.03   $18.03   $18.03   $18.73   $18.03  
FEHB 2   $20.48   $20.48   $20.48   $20.48   $20.48  
FEHB 3   $11.36   $15.80   $11.57   $15.39   $14.91  
Medicare  $23.64   $23.64   $23.64   $23.64   $23.64  
Medicaid  $20.87   $22.30   $13.92   $23.17   $17.50  
84443   FEHB 1   $15.55   $15.55   $16.16   $15.86   $15.55  
FEHB 2   $15.36   $15.36   $15.36   $15.36   $15.36  
FEHB 3   $10.52   $14.44   $10.25   $14.06   $13.61  
Medicare  $9.94   $10.94   $10.94   $10.94   $10.94  
Medicaid  $8.77   $10.32   $5.30   $10.72   $8.00  
85025   FEHB 1   $7.67   $13.03   $7.38   $7.53   $7.67  
FEHB 2   $5.03   $5.03   $5.43   $5.03   $5.03  
FEHB 3   $4.41   $8.69   $6.52   $7.10   $6.52  
Medicare  $5.53   $5.53   $5.53   $5.53   $5.53  
Medicaid  $4.88   $5.22   $3.00   $5.42   $3.50  
85610   FEHB 1   $5.82   $4.38   $4.22   $4.38   $4.38  
FEHB 2   $4.42   $5.12   $4.67   $5.12   $5.31  
FEHB 3   $3.73   $4.38   $3.29   $3.93   $4.38  
Medicare  $11.36   $11.36   $11.36   $11.36   $11.36  
Medicaid  $10.03   $10.72   $6.00   $11.13   $8.00  
87086   FEHB 1   $27.50   $22.50   $26.16   $17.00   $24.50  
FEHB 2   $10.45   $10.45   $10.45   $9.59   $10.45  
FEHB 3   $5.09   $6.94   $10.15   $7.37   $6.54  
continued on next page 
 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   27   
   
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS   State 
Insurer 
Code   GA  HI  IA  ID  IL 
Medicare  $11.91   $11.91   $11.91   $11.91   $11.91  
Medicaid  $10.65   $11.70   $11.31   $11.83   $8.28  
80048   FEHB 1   $12.55   $9.40   $12.31   $13.61   $10.85  
FEHB 2   $4.98   $12.93   $25.84   $13.12   $7.28  
FEHB 3   $13.01   $16.10   $14.50   $13.33   $4.50  
Medicare  $14.87   $14.87   $14.87   $14.87   $14.87  
Medicaid  $13.29   $14.61   $14.13   $14.77   $10.36  
80053   FEHB 1   $11.56   $22.47   $11.56   $16.35   $14.77  
FEHB 2   $6.19   $16.30   $30.60   $12.46   $9.00  
FEHB 3   $13.12   $20.10   $18.00   $18.32   $11.16  
Medicare  $18.85   $18.85   $18.85   $15.96   $18.85  
Medicaid  $16.85   $18.51   $17.91   $15.85   $6.22  
80061   FEHB 1   $13.69   $13.69   $13.69   $19.30   $13.69  
FEHB 2   $8.20   $20.50   $33.32   $18.72   $8.20  
FEHB 3   $18.72   $35.83   $23.00   $19.66   $17.00  
Medicare  $4.45   $4.45   $4.45   $4.45   $4.45  
Medicaid  $3.99   $4.37   $4.23   $4.43   $2.86  
81001   FEHB 1   $4.70   N/A  $4.76   $6.87   $4.43  
FEHB 2   $5.80   $4.97   $7.87   $7.97   $4.26  
FEHB 3   $4.65   $6.00   $5.50   $5.49   $4.50  
Medicare  $3.60   $3.60   $3.60   $3.60   $3.60  
Medicaid  $3.21   $3.54   $3.42   $3.57   $2.60  
81002   FEHB 1   $6.59   $4.52   $3.93   $5.53   $4.28  
FEHB 2   $5.33   $2.47   $7.24   $6.44   $3.89  
FEHB 3   $3.93   $4.61   $4.50   $4.43   $3.00  
Medicare  $3.16   $3.16   $3.16   $3.16   $3.16  
Medicaid  $2.83   $3.10   $3.00   $3.14   $2.18  
81003   FEHB 1   $5.24   N/A  $3.85   $3.86   $2.19  
FEHB 2   $5.33   $1.88   $5.58   $5.65   $3.02  
FEHB 3   $3.22   $3.86   $4.00   $3.90   $3.22  
Medicare  $41.66   $41.66   $41.66   $41.66   $41.66  
Medicaid  $37.22   $40.91   $39.58   $41.36   $8.86  
82306   FEHB 1   $36.21   $69.90   $43.30   $56.11   $36.21  
FEHB 2   $57.73   $57.73   $60.41   $57.73   $57.73  
FEHB 3   $33.09   $56.25   $51.00   $51.30   $30.00  
Medicare  $7.28   $7.28   $7.28   $7.28   $7.28  
Medicaid  $6.51   $7.15   $6.92   $7.23   $4.66  
82570   FEHB 1   $6.02   N/A  $7.61   $9.04   $5.79  
FEHB 2   $13.03   N/A  $13.03   $13.03   $13.03  
FEHB 3   $7.41   $9.85   $9.00   $8.97   $6.72  
Medicare  $21.21   $21.21   $21.21   $21.21   $21.21  
Medicaid  $18.95   $20.83   $20.15   $21.06   $12.00  
82607   FEHB 1   $16.65   N/A  $21.84   $31.40   $21.06  
FEHB 2   $19.71   N/A  $28.60   $19.71   $19.71  
FEHB 3   $18.71   $28.65   $26.00   $26.12   $15.00  
Medicare  $19.17   $16.09   $19.17   $19.17   $19.17  
Medicaid  $17.13   $15.81   $18.21   $19.03   $7.16  
82728   FEHB 1   $15.61   N/A  $19.86   $23.79   $20.56  
FEHB 2   $16.38   N/A  $33.89   $16.38   $16.38  
FEHB 3   $16.91   $21.75   $23.00   $23.61   $14.00  
continued on next page 
 
   
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   28   
   
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS   State 
Insurer 
Code   GA  HI  IA  ID  IL 
Medicare  $13.66   $13.66   $13.66   $9.84   $13.66  
Medicaid  $12.20   $13.42   $12.98   $9.77   $6.30  
83036   FEHB 1   $11.45   $11.45   $14.30   $14.39   $11.45  
FEHB 2   $12.35   $15.07   $24.16   $14.66   $12.35  
FEHB 3   $13.90   $18.45   $16.50   $12.12   $13.00  
Medicare  $9.12   $9.12   $9.12   $9.12   $9.12  
Medicaid  $8.15   $8.95   $8.66   $9.05   $6.38  
83540   FEHB 1   $7.80   N/A  $8.67   $8.15   $9.12  
FEHB 2   $5.12   N/A  $16.11   $5.12   $5.47  
FEHB 3   $7.24   $12.30   $11.00   $10.03   $6.00  
Medicare  $12.30   $12.30   $10.60   $12.30   $12.30  
Medicaid  $10.99   $12.08   $10.07   $12.21   $8.56  
83550   FEHB 1   $9.95   N/A  $11.33   N/A  $12.30  
FEHB 2   $12.28   N/A  $18.76   $12.28   $12.28  
FEHB 3   $10.85   $16.60   $13.00   $13.53   $9.00  
Medicare  $47.77   $47.77   $47.77   $47.77   $39.91  
Medicaid  $42.69   $28.46   $45.38   $47.43   $14.86  
83880   FEHB 1   $51.00   N/A  $49.64   $85.00   N/A 
FEHB 2   $117.39   N/A  N/A  N/A  $142.00  
FEHB 3   $42.75   $28.25   $58.00   $58.83   $4.50  
Medicare  $58.08   $58.08   $58.08   $58.08   $58.08  
Medicaid  $51.90   $57.04   $55.18   $57.67   $31.12  
83970   FEHB 1   $47.03   N/A  $55.94   $70.94   $45.27  
FEHB 2   $44.63   N/A  $70.72   $48.27   $48.27  
FEHB 3   $45.38   $78.45   $71.00   $65.62   $41.00  
Medicare  $25.89   $25.89   $25.89   $25.89   $25.89  
Medicaid  $23.13   $25.42   $24.60   $25.70   $13.20  
84153   FEHB 1   $18.73   $18.73   $18.73   $29.14   $18.73  
FEHB 2   $20.48   $28.79   $42.46   $26.85   $20.48  
FEHB 3   $25.70   $34.95   $32.00   $31.87   $18.00  
Medicare  $23.64   $23.64   $23.64   $22.14   $23.64  
Medicaid  $21.12   $23.21   $22.46   $21.98   $16.42  
84443   FEHB 1   $16.16   $38.48   $24.62   $25.99   $16.16  
FEHB 2   $15.36   $26.39   $41.78   $15.36   $15.36  
FEHB 3   $20.85   $31.90   $29.00   $27.26   $17.00  
Medicare  $10.94   $10.94   $10.94   $10.94   $10.94  
Medicaid  $9.77   $10.74   $10.39   $10.86   $5.74  
85025   FEHB 1   $13.07   $17.91   $11.52   $13.37   $11.14  
FEHB 2   $14.00   $11.94   $19.33   $12.35   $8.06  
FEHB 3   $10.86   $14.75   $13.50   $13.48   $5.18  
Medicare  $5.53   $5.53   $4.92   $5.53   $5.53  
Medicaid  $4.94   $5.43   $4.67   $5.49   $3.82  
85610   FEHB 1   $8.21   N/A  $6.30   $4.38   $5.62  
FEHB 2   $7.41   N/A  $11.97   $9.00   $6.72  
FEHB 3   $5.87   $7.45   $6.00   $6.80   $4.50  
Medicare  $11.36   $11.36   $11.36   $11.36   $11.36  
Medicaid  $10.15   $11.16   $10.79   $11.28   $10.50  
87086   FEHB 1   $24.50   N/A  $11.92   $17.48   $21.00  
FEHB 2   $10.45   $11.42   $24.00   $20.28   $10.45  
FEHB 3   $10.02   $15.35   $14.00   $14.00   $8.12  
continued on next page 
 
   
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   29   
   
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS   State 
Insurer 
Code   IN  KS  KY  LA  MA 
Medicare  $8.99   $11.91   $9.43   $11.91   $11.91  
Medicaid  $8.83   $10.50   $9.43   $9.61   $8.83  
80048   FEHB 1   $9.58   $9.23   $9.58   $12.55   $9.58  
FEHB 2   $4.98   $4.98   $12.00   $22.23   $4.98  
FEHB 3   $5.60   $13.32   $5.11   $2.58   $12.26  
Medicare  $14.65   $14.87   $11.83   $14.87   $14.87  
Medicaid  $14.39   $12.48   $11.83   $12.01   $11.03  
80053   FEHB 1   $11.12   $11.56   $11.56   $11.56   $11.56  
FEHB 2   $6.19   $6.19   $6.19   $11.73   $6.19  
FEHB 3   $9.12   $13.32   $7.12   $11.36   $16.50  
Medicare  $18.85   $18.85   $16.02   $16.82   $18.85  
Medicaid  $18.51   $15.12   $16.02   $12.34   $13.98  
80061   FEHB 1   $13.18   $13.18   $13.69   $13.69   $13.69  
FEHB 2   $8.20   $8.20   $8.20   $8.20   $8.20  
FEHB 3   $13.10   $30.82   $7.51   $12.84   $19.86  
Medicare  $4.45   $4.45   $4.45   $4.45   $4.45  
Medicaid  $4.37   $4.37   $4.45   $3.28   $3.31  
81001   FEHB 1   $5.32   $2.74   $5.34   $4.87   $2.74  
FEHB 2   $4.00   $3.80   $4.76   $7.75   $4.43  
FEHB 3   $3.77   $6.94   $3.30   $5.22   $4.74  
Medicare  $3.60   $3.60   $3.39   $3.60   $3.60  
Medicaid  $3.54   $3.01   $3.39   $2.64   $2.67  
81002   FEHB 1   $4.32   $2.99   $4.21   $4.61   $5.93  
FEHB 2   $4.00   $3.96   $3.69   $6.73   $3.48  
FEHB 3   $3.03   $5.80   $2.15   $4.29   $3.57  
Medicare  $3.16   $3.16   $3.16   $3.16   $3.16  
Medicaid  $3.10   $1.50   $3.16   $2.33   $2.34  
81003   FEHB 1   $3.79   $2.66   $4.11   $3.58   $3.94  
FEHB 2   $3.00   $3.47   $4.26   $5.50   $3.06  
FEHB 3   $2.67   $6.94   $1.38   $3.77   $3.51  
Medicare  $41.66   $41.66   $38.45   $41.66   $41.66  
Medicaid  $40.91   $10.08   $38.45   $30.59   $30.88  
82306   FEHB 1   $35.54   $35.54   $36.21   $36.21   $34.86  
FEHB 2   $57.73   $57.73   $57.73   $57.73   $57.73  
FEHB 3   $25.00   $43.36   $19.53   $31.80   $46.21  
Medicare  $7.28   $7.28   $7.28   $7.28   $7.28  
Medicaid  $7.15   $6.93   $7.28   $5.35   $5.40  
82570   FEHB 1   $6.02   $6.02   $7.67   $6.02   $6.02  
FEHB 2   $10.61   $13.03   $10.13   $13.03   $13.03  
FEHB 3   $4.54   $8.72   $3.20   $6.28   $7.68  
Medicare  $21.21   $21.21   $21.21   $21.21   $21.05  
Medicaid  $20.83   $20.83   $21.21   $15.57   $15.61  
82607   FEHB 1   $16.65   $16.03   $16.03   $16.65   $16.34  
FEHB 2   $19.71   $19.71   $19.71   $19.71   $20.04  
FEHB 3   $13.21   $22.08   $10.28   $16.19   $23.36  
Medicare  $19.17   $19.17   $19.17   $19.17   $19.17  
Medicaid  $18.83   $18.83   $19.17   $14.07   $14.21  
82728   FEHB 1   $15.48   $15.03   $15.03   $21.79   $15.03  
FEHB 2   $16.38   $16.38   $16.38   $16.38   $16.38  
FEHB 3   $11.93   $19.96   $9.12   $14.63   $20.20  
continued on next page 
 
   
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   30   
   
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS   State 
Insurer 
Code   IN  KS  KY  LA  MA 
Medicare  $13.66   $13.66   $13.66   $13.66   $13.66  
Medicaid  $13.42   $13.41   $13.66   $10.03   $10.13  
83036   FEHB 1   $11.45   $11.45   $11.45   $11.45   $11.45  
FEHB 2   $12.35   $12.35   $12.35   $12.35   $12.35  
FEHB 3   $8.50   $27.08   $8.91   $10.43   $14.40  
Medicare  $9.12   $9.12   $9.12   $7.55   $9.12  
Medicaid  $8.95   $5.20   $9.12   $5.54   $6.76  
83540   FEHB 1   $7.80   $7.51   $8.40   $9.30   $7.51  
FEHB 2   $5.12   $5.12   $5.12   $5.12   $5.12  
FEHB 3   $5.68   $9.49   $4.11   $5.76   $9.97  
Medicare  $12.30   $12.30   $12.30   $12.30   $12.30  
Medicaid  $12.08   $12.18   $12.30   $9.04   $9.12  
83550   FEHB 1   $9.95   $9.57   $9.57   $14.04   $9.76  
FEHB 2   $12.28   $12.28   $13.50   $12.28   $12.28  
FEHB 3   $7.66   $15.34   $5.77   $12.30   $13.06  
Medicare  $40.85   $43.37/$47.77   $47.77   $47.77   $47.77  
Medicaid  $40.56   $23.10   $47.77   $38.97   $35.42  
83880   FEHB 1   $47.65   $45.87   $53.47   $68.43   $47.65  
FEHB 2   $142.00   $149.10   $136.60   $100.80   $45.50  
FEHB 3   $25.43   $38.07   $22.45   $16.00   $49.70  
Medicare  $58.08   $58.08   $58.08   $58.08   $58.08  
Medicaid  $57.04   $23.10   $58.08   $42.65   $43.06  
83970   FEHB 1   $58.08   $45.27   $45.27   $47.03   $45.27  
FEHB 2   $44.63   $44.63   $44.63   $44.63   $44.63  
FEHB 3   $34.85   $116.76   $28.37   $41.07   $61.22  
Medicare  $25.89   $25.89   $25.89   $25.89   $25.89  
Medicaid  $25.42   $21.61   $25.89   $19.00   $19.19  
84153   FEHB 1   $18.03   $18.73   $18.73   $18.73   $18.73  
FEHB 2   $20.48   $20.48   $20.48   $20.48   $20.48  
FEHB 3   $21.85   $51.19   $12.00   $19.76   $28.72  
Medicare  $23.64   $23.64   $23.64   $23.64   $23.64  
Medicaid  $23.21   $15.75   $23.64   $17.36   $17.53  
84443   FEHB 1   $15.55   $16.16   $24.90   $16.16   $16.16  
FEHB 2   $15.36   $15.36   $15.36   $23.00   $15.36  
FEHB 3   $14.72   $27.00   $11.32   $18.05   $25.77  
Medicare  $10.94   $6.54/$10.94   $10.94   $10.94   $10.94  
Medicaid  $10.74   $5.00   $10.94   $8.03   $8.11  
85025   FEHB 1   $7.67   $7.67   $13.58   $12.38   $7.67  
FEHB 2   $5.03   $5.03   $11.14   $20.41   $8.00  
FEHB 3   $7.60   $9.55   $5.18   $11.52   $11.53  
Medicare  $5.53   $5.53   $5.53   $5.53   $5.53  
Medicaid  $5.43   $5.25   $5.53   $4.07   $4.10  
85610   FEHB 1   $4.22   $4.38   $6.86   $6.37   $4.38  
FEHB 2   $6.18   $6.08   $5.62   $10.32   $5.67  
FEHB 3   $3.44   $12.11   $4.31   $3.79   $5.84  
Medicare  $11.36   $11.36   $11.36   $11.36   $11.36  
Medicaid  $11.16   $10.50   $11.36   $8.34   $8.42  
87086   FEHB 1   $24.50   $24.50   $24.50   $24.50   $20.00  
FEHB 2   $10.45   $10.45   $10.45   $10.45   $10.72  
FEHB 3   $7.95   $21.68   $8.54   $8.68   $12.60  
continued on next page 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   31   
   
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS   State 
Insurer 
Code   MD  ME  MI  MN  MO 
Medicare  $11.91   $11.91   $11.91   $11.91   $11.91  
Medicaid  $9.01   $7.02   $9.31   $11.91   $11.12  
80048   FEHB 1   $9.23   $9.58   $9.41   $24.86   $9.58  
FEHB 2   $4.98   $8.09   $4.98   $33.30   $4.98  
FEHB 3   $9.30   $12.69   $8.68   $13.94   $10.28  
Medicare  $14.87   $14.87   $14.65   $14.87   $14.87  
Medicaid  $11.25   $8.76   $11.43   $14.87   $13.73  
80053   FEHB 1   $11.12   $19.58   $11.56   $29.32   $11.56  
FEHB 2   $6.19   $6.19   $6.19   $41.40   $6.19  
FEHB 3   $9.76   $14.61   $15.19   $17.41   $12.39  
Medicare  $17.17   $18.85   $17.98   $18.85   $18.85  
Medicaid  $12.98   $17.10   $12.53   $18.85   $17.61  
80061   FEHB 1   $13.18   $25.27   $13.69   $43.50   $13.69  
FEHB 2   $8.20   $8.20   $8.20   $52.20   $8.20  
FEHB 3   $12.36   $20.34   $11.78   $22.07   $16.64  
Medicare  $4.45   $4.45   $4.45   $4.45   $4.45  
Medicaid  $3.38   $3.42   $2.64   $4.45   $4.17  
81001   FEHB 1   $2.64   $6.42   $2.74   $13.95   $2.74  
FEHB 2   $3.80   $5.90   $4.97   $14.18   $3.80  
FEHB 3   $2.92   $4.81   $2.92   $6.40   $4.99  
Medicare  $3.60   $3.60   $3.60   $3.60   $2.94/$3.60  
Medicaid  $2.72   $3.42   $1.10   $3.60   $1.83  
81002   FEHB 1   $5.50   $4.82   $6.50   $9.11   $4.28  
FEHB 2   $2.24   $4.03   $4.27   $5.71   $3.96  
FEHB 3   $2.80   $3.52   $3.73   $4.21   $3.36  
Medicare  $3.16   $3.16   $3.16   $3.16   $2.94/$3.16  
Medicaid  $2.39   $3.18   $1.10   $3.16   $1.83  
81003   FEHB 1   $2.20   $4.24   $3.22   $10.93   $3.33  
FEHB 2   $2.67   $3.54   $3.50   $9.00   $3.47  
FEHB 3   $2.50   $3.09   $3.28   $3.70   $3.29  
Medicare  $41.66   $41.66   $41.66   $41.66   $41.66  
Medicaid  $31.50   $41.36   $32.53   $41.66   $38.90  
82306   FEHB 1   $34.86   $66.56   $36.21   $43.88   $34.86  
FEHB 2   $57.73   $57.73   $57.73   $105.45   $57.73  
FEHB 3   $18.61   $42.04   $27.30   $59.78   $33.39  
Medicare  $5.78   $7.28   $6.54   $7.22   $7.28  
Medicaid  $4.19   $5.40   $3.42   $7.22   $5.50  
82570   FEHB 1   $6.02   $5.91   $6.02   $19.40   $6.02  
FEHB 2   $12.75   $13.03   $10.85   $13.03   $13.03  
FEHB 3   $4.82   $7.14   $4.29   $8.45   $5.85  
Medicare  $21.21   $21.05   $21.21   $21.21   $21.21  
Medicaid  $16.03   $11.16   $10.92   $21.21   $19.81  
82607   FEHB 1   $16.03   $16.65   $16.65   $38.00   $16.65  
FEHB 2   $19.71   $19.71   $21.56   $19.71   $19.71  
FEHB 3   $12.21   $20.68   $13.90   $30.44   $17.66  
Medicare  $19.17   $19.17   $19.17   $19.17   $19.17  
Medicaid  $14.49   $18.90   $14.55   $19.17   $17.90  
82728   FEHB 1   $15.03   $25.69   $15.61   $55.80   $15.61  
FEHB 2   $16.20   N/A  $16.38   $43.54   $16.38  
FEHB 3   $12.57   $18.80   $12.56   $27.51   $15.97  
continued on next page 
   
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   32   
   
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS   State 
Insurer 
Code   MD  ME  MI  MN  MO 
Medicare  $13.10   $13.66   $13.66   $13.66   $13.66  
Medicaid  $9.91   $11.25   $8.64   $13.66   $12.75  
83036   FEHB 1   $11.02   $18.31   $11.45   $35.20   $11.02  
FEHB 2   $12.35   $12.35   $12.35   $37.80   $12.35  
FEHB 3   $8.96   $13.65   $8.95   $15.99   $13.56  
Medicare  $9.12   $9.12   $9.12   $9.12   $9.12  
Medicaid  $6.90   $5.40   $3.96   $9.12   $8.51  
83540   FEHB 1   $7.51   $7.80   $7.80   $21.60   $7.80  
FEHB 2   $5.12   N/A  $5.12   $28.37   $5.12  
FEHB 3   $4.07   $8.60   $5.98   $13.08   $7.59  
Medicare  $12.30   $12.30   $12.13   $12.30   $12.30  
Medicaid  $8.93   $6.47   $6.36   $12.30   $7.70  
83550   FEHB 1   $9.57   $9.95   $9.57   $21.24   $9.95  
FEHB 2   $10.38   N/A  $12.28   $34.20   $12.28  
FEHB 3   $8.06   $12.06   $7.96   $17.65   $9.86  
Medicare  $47.77   $47.77   $47.77   $47.77   $39.27/$43.37  
Medicaid  $36.12   $21.34   $37.70   $47.77   $38.99  
83880   FEHB 1   $48.99   $63.75   $72.25   N/A  $45.87  
FEHB 2   $90.46   N/A  N/A  $174.60   $148.75  
FEHB 3   $42.75   $51.85   $31.30   $55.91   $42.75  
Medicare  $58.08   $58.08   $58.08   $58.08   $58.08  
Medicaid  $43.92   $52.65   $45.35   $58.08   $51.15  
83970   FEHB 1   $45.27   $80.72   $46.15   $61.18   $46.75  
FEHB 2   $44.63   N/A  $44.63   $230.91   $44.63  
FEHB 3   $38.10   $58.58   $38.06   $83.36   $60.46  
Medicare  $25.89   $25.89   $25.89   $25.89   $25.89  
Medicaid  $19.58   $25.42   $19.42   $25.89   $24.17  
84153   FEHB 1   $18.73   $34.76   $18.73   $47.00   $18.73  
FEHB 2   $20.48   $20.48   $20.48   $135.18   $20.48  
FEHB 3   $16.98   $26.11   $16.96   $30.00   $21.56  
Medicare  $23.64   $23.64   $23.64   $23.64   $23.64  
Medicaid  $17.88   $20.52   $8.27   $23.64   $22.08  
84443   FEHB 1   $16.16   $31.68   $16.16   $62.00   $16.16  
FEHB 2   $15.36   $15.36   $15.36   $65.70   $15.36  
FEHB 3   $15.51   $23.84   $15.49   $27.67   $22.08  
Medicare  $10.94   $10.94   $10.93   $10.94   $10.94  
Medicaid  $8.28   $10.74   $4.96   $10.94   $10.22  
85025   FEHB 1   $7.67   $14.66   $11.52   $22.45   $7.67  
FEHB 2   $5.03   $7.13   $10.56   $34.38   $11.73  
FEHB 3   $7.17   $10.86   $8.12   $15.71   $12.00  
Medicare  $5.30   $5.53   $5.53   $5.53   $5.53  
Medicaid  $4.00   $4.59   $3.64   $5.53   $3.85  
85610   FEHB 1   $4.38   $7.41   $5.66   $12.63   $4.38  
FEHB 2   $5.12   $6.18   $6.15   $17.57   $6.08  
FEHB 3   $3.63   $5.58   $5.53   $6.46   $6.00  
Medicare  $11.36   $11.36   $11.36   $11.36   $9.84/$11.36  
Medicaid  $8.59   $5.98   $4.42   $11.36   $9.77  
87086   FEHB 1   $26.16   $20.00   $21.38   $18.11   $24.50  
FEHB 2   $9.59   $12.38   $10.45   $31.50   $10.45  
FEHB 3   $10.13   $12.43   $7.45   $16.31   $9.11  
continued on next page 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   33   
   
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS   State 
Insurer 
Code   MS  MT  NC  ND  NE 
Medicare  $11.91   $11.91   $11.28   $11.91   $11.91  
Medicaid  $10.91   $11.91   $10.19   $12.12   $11.91  
80048   FEHB 1   $17.35   $21.23   $12.55   $52.11   $18.01  
FEHB 2   $32.00   $24.84   $7.56   $21.29   $25.82  
FEHB 3   $31.00   $18.18   $7.28   $25.86   $20.60  
Medicare  $14.87   $14.87   $11.89   $14.87   $14.87  
Medicaid  $13.63   $14.86   $10.74   $15.14   $14.87  
80053   FEHB 1   $21.69   $29.32   $12.98   $35.18   $22.17  
FEHB 2   $25.00   $31.02   $6.19   $36.90   $28.80  
FEHB 3   $47.00   $22.71   $5.35   $32.31   $25.74  
Medicare  $18.85   $18.85   $18.85   $17.17   $18.85  
Medicaid  $17.27   $18.85   $17.04   $17.48   $18.85  
80061   FEHB 1   $19.00   $43.50   $18.72   $81.08   $27.62  
FEHB 2   $21.00   $32.97   $8.20   $46.85   $34.00  
FEHB 3   $42.00   $28.79   $8.48   $37.30   $32.62  
Medicare  $4.45   $4.45   $4.45   $4.45   $4.45  
Medicaid  $4.09   $4.45   $4.03   $4.54   $4.45  
81001   FEHB 1   $11.00   $11.63   $3.65   $25.91   $6.33  
FEHB 2   $11.00   $9.30   $4.02   $13.85   $6.80  
FEHB 3   $10.00   $6.81   $6.14   $9.69   $7.72  
Medicare  $3.60   $3.60   $3.60   $3.60   $3.60  
Medicaid  $3.29   $3.60   $3.25   $3.66   $3.60  
81002   FEHB 1   $9.00   $6.00   $7.65   $9.11   $5.78  
FEHB 2   $9.00   $7.68   $3.65   $11.00   $7.80  
FEHB 3   $9.88   $5.49   $5.36   $7.81   $6.42  
Medicare  $3.16   $3.16   $3.16   $3.16   $3.16  
Medicaid  $2.90   $3.16   $2.86   $3.22   $3.16  
81003   FEHB 1   $6.45   $9.11   $4.86   N/A  $5.20  
FEHB 2   $9.11   $4.40   $3.65   $8.10   $6.86  
FEHB 3   $7.68   $4.83   $4.71   $6.87   $5.67  
Medicare  $41.66   $41.66   $41.66   $41.66   $41.66  
Medicaid  $38.16   $41.65   $37.64   $42.40   $41.66  
82306   FEHB 1   $90.00   $105.00   $41.36   N/A  $58.73  
FEHB 2   $93.00   $80.23   $57.73   $107.45   $83.00  
FEHB 3   $85.00   $63.60   $18.61   $100.00   $72.08  
Medicare  $6.54   $7.28   $7.28   $7.28   $7.28  
Medicaid  $5.99   $7.27   $6.58   $7.41   $7.28  
82570   FEHB 1   $7.67   $16.17   $7.23   $16.17   $6.75  
FEHB 2   $16.00   $16.00   $10.13   $19.80   $13.03  
FEHB 3   $14.00   $11.12   $4.70   $15.81   $12.60  
Medicare  $21.21   $21.21   $21.21   $21.21   $21.21  
Medicaid  $19.43   $21.21   $19.16   $21.59   $21.21  
82607   FEHB 1   $26.33   $33.70   $21.06   $45.00   $31.90  
FEHB 2   $47.00   $34.00   $23.17   $53.00   $31.86  
FEHB 3   $45.00   $32.39   $9.48   $46.08   $36.70  
Medicare  $19.17   $19.17   $19.17   $19.17   $19.17  
Medicaid  $17.56   $19.17   $17.32   $19.51   $19.17  
82728   FEHB 1   $15.61   $46.50   $20.19   $46.50   $22.19  
FEHB 2   $37.00   $16.38   $16.38   $19.03   $40.00  
FEHB 3   $41.00   $29.27   $8.56   $41.63   $33.17  
continued on next page 
 
 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   34   
   
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS   State 
Insurer 
Code   MS  MT  NC  ND  NE 
Medicare  $13.66   $13.66   $13.66   $13.66   $13.66  
Medicaid  $12.51   $13.66   $12.34   $13.90   $13.66  
83036   FEHB 1   $11.45   $29.33   $13.42   $59.23   $21.84  
FEHB 2   $26.00   $29.00   $12.35   $32.40   $25.00  
FEHB 3   $29.00   $20.85   $8.96   $29.66   $23.63  
Medicare  $9.12   $6.10   $9.12   $9.12   $9.12  
Medicaid  $8.35   $6.10   $8.24   $9.28   $9.12  
83540   FEHB 1   $16.25   N/A  $9.60   $18.00   $8.15  
FEHB 2   $13.47   $5.12   $5.12   $21.60   $5.12  
FEHB 3   $19.00   $9.32   $4.07   $19.81   $15.78  
Medicare  $12.30   $7.63   $12.30   $12.30   $12.30  
Medicaid  $11.27   $7.63   $11.11   $12.52   $12.31  
83550   FEHB 1   $31.00   N/A  $12.95   $17.70   $14.23  
FEHB 2   $12.28   $12.28   $12.21   $12.21   $12.28  
FEHB 3   $28.00   $11.66   $5.49   $26.72   $21.28  
Medicare  $47.77   $47.77   $47.77   $47.77   $47.77  
Medicaid  $43.76   $47.77   $43.16   $48.62   $47.77  
83880   FEHB 1   $50.32   N/A  $56.00   N/A  N/A 
FEHB 2   $117.99   N/A  $66.53   N/A  $98.86  
FEHB 3   $42.75   $72.93   $42.75   $105.83   $82.65  
Medicare  $58.08   $58.08   $58.08   $58.08   $58.08  
Medicaid  $53.21   $58.08   $52.48   $59.12   $58.08  
83970   FEHB 1   $45.27   N/A  $61.18   N/A  $51.90  
FEHB 2   $136.00   N/A  $43.25   N/A  $126.03  
FEHB 3   $139.00   $88.68   $31.72   $128.68   $100.50  
Medicare  $22.12   $25.89   $25.89   $25.89   $25.89  
Medicaid  $20.26   $25.89   $23.39   $26.34   $25.89  
84153   FEHB 1   $21.85   $38.25   $25.70   $80.80   $39.19  
FEHB 2   $49.00   $45.00   $20.48   $59.40   $47.06  
FEHB 3   $50.00   $39.51   $12.36   $56.21   $44.78  
Medicare  $22.89   $23.64   $22.93   $23.64   $23.64  
Medicaid  $20.97   $23.64   $20.72   $24.06   $23.64  
84443   FEHB 1   $22.43   $52.50   $24.90   $52.50   $26.91  
FEHB 2   $47.00   $51.00   $15.36   $61.15   $38.73  
FEHB 3   $46.00   $36.09   $10.32   $51.35   $40.90  
Medicare  $10.94   $10.94   $10.94   $10.94   $6.54  
Medicaid  $10.03   $10.93   $9.88   $11.14   $6.54  
85025   FEHB 1   $21.00   $18.71   $11.52   $22.45   $17.42  
FEHB 2   $25.00   $22.81   $10.29   $31.05   $14.19  
FEHB 3   $21.00   $16.71   $9.68   $23.77   $11.32  
Medicare  $5.53   $5.53   $5.53   $5.53   $5.53  
Medicaid  $5.06   $5.53   $5.00   $5.62   $5.53  
85610   FEHB 1   $13.00   $8.78   $6.76   $48.88   $9.24  
FEHB 2   $13.00   $8.90   $5.43   $15.30   $11.97  
FEHB 3   $14.00   $8.43   $5.62   $11.99   $9.55  
Medicare  $11.36   $11.36   $11.36   $11.36   $11.36  
Medicaid  $10.41   $11.35   $10.26   $11.57   $11.36  
87086   FEHB 1   $21.00   $28.00   $19.06   $25.28   $16.41  
FEHB 2   $21.00   $11.28   $8.46   $86.45   $20.00  
FEHB 3   $23.00   $17.36   $10.15   $24.69   $19.67  
continued on next page 
 
   
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   35   
   
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS   State 
Insurer 
Code   NH  NJ  NM  NV  NY 
Medicare  $11.91   $11.91   $11.91   $11.91   $8.99/$11.28  
Medicaid  $7.27   $9.53   $11.91   $5.92   $7.25  
80048   FEHB 1   $9.23   $9.30   $10.10   $9.41   $9.58  
FEHB 2   $4.98   $4.98   $25.16   $4.98   $4.98  
FEHB 3   $12.69   $10.00   $8.31   $5.68   $6.85  
Medicare  $14.87   $13.45   $14.87   $14.87   $13.45/$14.87  
Medicaid  $9.08   $10.76   $14.87   $7.39   $10.00  
80053   FEHB 1   $11.12   $11.12   $11.12   $11.12   $11.56  
FEHB 2   $6.19   $6.19   $31.41   $6.19   $6.19  
FEHB 3   $16.50   $11.30   $15.14   $8.85   $8.48  
Medicare  $18.85   $18.85   $17.27   $18.85   $18.85  
Medicaid  $11.51   $15.08   $17.27   $9.36   $6.04  
80061   FEHB 1   $13.18   $13.18   $13.18   $13.18   $13.69  
FEHB 2   $8.20   $8.20   $36.49   $8.20   $8.20  
FEHB 3   $19.43   $16.12   $14.59   $11.21   $11.74  
Medicare  $4.45   $4.45   $4.45   $4.45   $4.45  
Medicaid  $2.72   $3.56   $4.45   $2.22   $4.00  
81001   FEHB 1   $2.64   $2.64   $4.76   $2.64   $2.64  
FEHB 2   $5.27   $3.80   $9.40   $3.80   $3.80  
FEHB 3   $4.27   $3.74   $3.77   $2.65   $2.78  
Medicare  $3.60   $3.60   $3.60   $3.60   $3.60  
Medicaid  $2.20   $2.88   $3.60   $1.79   $2.00  
81002   FEHB 1   $5.52   $4.00   $5.36   $2.50   $5.00  
FEHB 2   $4.03   $3.74   $7.61   $2.66   $9.96  
FEHB 3   $3.57   $3.21   $3.66   $1.67   $2.52  
Medicare  $2.51   $3.16   $3.16   $3.16   $3.16  
Medicaid  $1.53   $2.53   $3.16   $1.58   $2.00  
81003   FEHB 1   $3.49   $2.11   $2.19   $2.11   $2.20  
FEHB 2   $2.85   $2.85   $6.09   $2.85   $3.61  
FEHB 3   $2.40   $2.70   $3.22   $1.50   $2.51  
Medicare  $41.66   $41.66   $41.66   $41.24   $40.85/$41.66  
Medicaid  $25.44   $33.33   $41.66   $20.47   $36.60  
82306   FEHB 1   $34.86   $34.86   $34.86   $43.88   $34.86  
FEHB 2   $57.73   $57.73   $87.96   $57.73   $57.73  
FEHB 3   $46.21   $34.99   $29.09   $19.38   $25.93  
Medicare  $7.28   $7.28   $7.07   $7.28   $6.15/$7.28  
Medicaid  $4.45   $5.82   $7.07   $3.62   $5.03  
82570   FEHB 1   $5.79   $5.79   $6.02   $5.79   $5.79  
FEHB 2   $13.03   $13.03   $14.92   $13.03   $13.03  
FEHB 3   $6.97   $6.22   $4.94   $4.33   $4.54  
Medicare  $16.89   $21.21   $21.21   $21.21   $20.67/$21.21  
Medicaid  $10.31   $16.97   $21.21   $10.53   $12.50  
82607   FEHB 1   $16.03   $16.65   $16.03   $16.03   $16.03  
FEHB 2   $19.71   $19.71   $44.78   $19.71   $19.71  
FEHB 3   $15.69   $17.82   $14.81   $12.62   $13.21  
Medicare  $19.17   $19.17   $19.17   $19.17   $19.17  
Medicaid  $11.71   $15.34   $19.17   $9.52   $14.75  
82728   FEHB 1   $15.03   $15.07   $20.93   $15.03   $15.34  
FEHB 2   $16.38   $16.38   $40.48   $16.38   $16.38  
FEHB 3   $14.20   $16.10   $13.38   $11.40   $11.93  
continued on next page 
 
   
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   36   
   
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS   State 
Insurer 
Code   NH  NJ  NM  NV  NY 
Medicare  $13.66   $13.66   $13.66   $13.66   $13.66  
Medicaid  $8.34   $10.93   $13.66   $6.79   $10.64  
83036   FEHB 1   $11.02   $11.02   $11.02   $11.02   $11.45  
FEHB 2   $12.35   $12.35   $17.00   $12.35   $12.35  
FEHB 3   $14.20   $11.47   $11.54   $8.12   $8.50  
Medicare  $9.12   $9.12   $9.12   $8.02   $9.12  
Medicaid  $5.57   $7.30   $9.12   $3.99   $5.03  
83540   FEHB 1   $7.51   $7.51   $8.40   $7.51   $7.51  
FEHB 2   $5.12   $5.12   $19.24   $5.12   $5.12  
FEHB 3   $9.24   $6.50   $6.37   $5.42   $5.68  
Medicare  $12.30   $12.30   $12.30   $9.85   $12.30  
Medicaid  $7.51   $9.84   $12.30   $4.89   $5.03  
83550   FEHB 1   $9.57   $9.81   $9.57   $9.57   $9.95  
FEHB 2   $12.13   $12.28   $31.45   $12.28   $12.28  
FEHB 3   $8.76   $10.33   $8.59   $7.32   $7.66  
Medicare  $47.77   $47.77   $47.77   $47.77   $44.12/$47.77  
Medicaid  $29.17   $38.22   $47.77   $23.72   $34.07  
83880   FEHB 1   N/A  $47.43   N/A  $46.76   $45.87  
FEHB 2   N/A  $149.30   $121.55   $164.91   $58.38  
FEHB 3   $52.99   $42.75   $30.46   $28.41   $34.03  
Medicare  $58.08   $58.08   $58.08   $58.08   $58.08  
Medicaid  $35.47   $46.46   $58.08   $28.84   $52.32  
83970   FEHB 1   $45.27   $45.27   $45.27   $45.27   $47.03  
FEHB 2   $44.63   $44.63   $147.90   $44.63   $44.63  
FEHB 3   $52.83   $48.79   $49.07   $34.54   $36.16  
Medicare  $20.43   $25.89   $25.89   $25.89   $25.89  
Medicaid  $12.47   $20.71   $25.89   $12.86   $24.35  
84153   FEHB 1   $18.03   $18.03   $18.03   $18.03   $18.73  
FEHB 2   $20.48   $20.48   $54.65   $20.48   $20.48  
FEHB 3   $28.31   $21.75   $18.07   $15.39   $16.11  
Medicare  $23.64   $23.64   $23.64   $23.64   $23.64  
Medicaid  $14.44   $18.91   $23.64   $11.74   $9.00  
84443   FEHB 1   $15.55   $16.16   $15.55   $15.55   $16.16  
FEHB 2   $15.36   $15.36   $49.90   $15.36   $15.36  
FEHB 3   $25.85   $19.86   $19.97   $14.06   $16.08  
Medicare  $10.94   $10.94   $10.94   $10.94   $10.88/$10.94  
Medicaid  $6.68   $8.75   $10.94   $5.43   $3.17  
85025   FEHB 1   $7.67   $7.67   $7.67   $7.60   $8.60  
FEHB 2   $5.03   $5.03   $23.09   $5.03   $10.97  
FEHB 3   $11.09   $9.36   $11.14   $5.37   $8.06  
Medicare  $5.53   $5.53   $5.53   $5.53   $5.53  
Medicaid  $3.37   $4.42   $5.53   $2.75   $3.91  
85610   FEHB 1   $4.38   $4.38   $5.74   $4.22   $4.38  
FEHB 2   $5.65   $5.12   $9.35   $5.12   $5.56  
FEHB 3   $5.59   $4.72   $5.62   $2.68   $3.47  
Medicare  $9.03   $11.36   $11.25   $11.36   $11.36  
Medicaid  $5.51   $9.09   $11.25   $5.64   $8.15  
87086   FEHB 1   $20.00   $22.48   $27.50   $24.50   $22.48  
FEHB 2   $15.00   $10.45   $16.15   $10.45   $10.45  
FEHB 3   $12.43   $9.54   $7.85   $6.75   $7.07  
continued on next page 
   
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   37   
   
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS   State 
Insurer 
Code   OH  OK  OR  PA  RI 
Medicare  $10.33   $11.91   $11.91   $11.91   $11.91  
Medicaid  $8.47   $10.95   $8.97   $9.36   $7.10  
80048   FEHB 1   $9.23   $9.23   $13.01   $9.23   N/A 
FEHB 2   $4.98   $4.98   $17.45   $4.98   $4.98  
FEHB 3   $3.47   $16.56   $14.20   $8.48   $12.36  
Medicare  $14.87   $14.87   $14.87   $14.87   $14.87  
Medicaid  $14.17   $13.67   $11.20   $11.69   $8.86  
80053   FEHB 1   $11.12   $11.12   $15.14   $11.12   N/A 
FEHB 2   $6.19   $6.19   $21.80   $6.19   $6.19  
FEHB 3   $5.00   $20.68   $18.17   $10.60   $15.44  
Medicare  $17.89   $18.85   $18.85   $18.85   $18.85  
Medicaid  $17.04   $17.33   $14.20   $14.00   $11.23  
80061   FEHB 1   $13.18   $13.69   $19.30   $13.18   N/A 
FEHB 2   $8.20   $8.20   $27.63   $8.20   $8.20  
FEHB 3   $6.02   $26.21   $23.03   $21.62   $19.57  
Medicare  $4.45   $4.45   $4.45   $4.45   $4.45  
Medicaid  $4.24   $4.09   $3.36   $4.37   $2.66  
81001   FEHB 1   $2.64   $4.34   $9.30   $2.74   N/A 
FEHB 2   $3.80   $2.78   $6.81   $3.80   $3.80  
FEHB 3   $3.90   $6.20   $5.45   $3.18   $4.63  
Medicare  $3.32   $3.30   $3.60   $3.60   $3.60  
Medicaid  $3.16   $3.03   $2.71   $3.57   $2.14  
81002   FEHB 1   $2.36   $3.34   $5.10   $4.11   N/A 
FEHB 2   $2.26   $2.14   $5.27   $4.39   $3.99  
FEHB 3   $2.77   $4.59   $4.39   $2.56   $3.57  
Medicare  $3.16   $3.16   $3.16   $3.16   $2.69  
Medicaid  $3.01   $2.90   $2.38   $3.10   $1.60  
81003   FEHB 1   $1.87   $2.91   $3.67   $2.19   N/A 
FEHB 2   $1.74   $1.88   $4.64   $2.85   $2.85  
FEHB 3   $1.06   $4.40   $3.86   $2.25   $2.67  
Medicare  $41.66   $41.66   $33.77   $41.66   $41.66  
Medicaid  $39.68   $38.29   $25.43   $40.91   $24.82  
82306   FEHB 1   $34.86   $36.21   $36.21   $34.86   N/A 
FEHB 2   $57.73   $57.73   $57.73   $57.73   $57.73  
FEHB 3   $14.00   $57.90   $34.37   $29.68   $43.22  
Medicare  $7.28   $7.28   $7.28   $7.28   $7.28  
Medicaid  $6.94   $6.69   $5.48   $7.15   $4.34  
82570   FEHB 1   $5.79   $5.79   $7.95   $5.79   N/A 
FEHB 2   $6.77   $6.15   $12.65   $13.03   $10.35  
FEHB 3   $2.45   $10.12   $7.41   $5.19   $7.23  
Medicare  $21.21   $21.21   $21.21   $21.21   $21.21  
Medicaid  $20.21   $19.49   $15.98   $13.00   $12.64  
82607   FEHB 1   $16.03   $16.03   $16.65   $16.03   N/A 
FEHB 2   $19.71   $19.71   $29.12   $19.71   $19.71  
FEHB 3   $7.13   $29.48   $21.59   $15.11   $22.01  
Medicare  $19.17   $19.17   $12.31   $19.17   $19.17  
Medicaid  $18.27   $17.62   $9.27   $12.00   $11.42  
82728   FEHB 1   $15.03   $15.03   $15.03   $15.61   N/A 
FEHB 2   $16.38   $16.38   $17.88   $16.38   $29.19  
FEHB 3   $6.44   $26.64   $12.53   $13.66   $19.89  
continued on next page 
 
 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   38   
   
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS   State 
Insurer 
Code   OH  OK  OR  PA  RI 
Medicare  $13.66   $12.16   $13.66   $13.66   $12.31  
Medicaid  $13.02   $11.18   $10.29   $7.00   $7.33  
83036   FEHB 1   $11.02   $11.02   $13.05   $11.02   N/A 
FEHB 2   $12.35   $12.35   $20.02   $12.35   $12.35  
FEHB 3   $9.00   $16.91   $16.68   $9.73   $12.77  
Medicare  $9.12   $7.84   $9.12   $9.12   $9.12  
Medicaid  $8.68   $7.21   $6.87   $8.45   $5.43  
83540   FEHB 1   $7.51   $7.51   $7.80   $7.80   N/A 
FEHB 2   $5.12   $5.12   $9.12   $5.12   $10.06  
FEHB 3   $3.06   $10.89   $9.28   $6.50   $9.46  
Medicare  $12.30   $12.30   $12.30   $12.30   $12.30  
Medicaid  $11.72   $11.31   $9.26   $5.00   $7.33  
83550   FEHB 1   $9.57   $9.57   $9.95   $9.95   N/A 
FEHB 2   $12.28   $12.28   $12.28   $12.28   $16.14  
FEHB 3   $4.13   $18.32   $12.52   $8.76   $12.77  
Medicare  $47.77   $47.77   $47.77   $47.77   $47.77  
Medicaid  $46.01   $43.91   $35.98   $37.94   $28.46  
83880   FEHB 1   $45.87   $45.87   $56.92   $45.87   N/A 
FEHB 2   $65.55   $142.00   $140.28   $156.60   N/A 
FEHB 3   $16.06   $57.00   $48.62   $34.03   $47.43  
Medicare  $58.08   $58.08   $58.08   $58.08   $58.08  
Medicaid  $57.04   $53.38   $43.75   $42.50   $34.60  
83970   FEHB 1   $45.27   $45.27   $47.03   $47.03   N/A 
FEHB 2   $44.63   $40.99   $44.63   $44.63   N/A 
FEHB 3   $19.53   $80.74   $59.12   $41.38   $60.27  
Medicare  $25.89   $25.89   $25.89   $25.89   $25.80  
Medicaid  $24.66   $23.80   $19.49   $24.36   $15.37  
84153   FEHB 1   $18.03   $18.03   $27.26   $18.03   N/A 
FEHB 2   $20.48   $20.48   $37.08   $20.48   $20.48  
FEHB 3   $8.70   $35.98   $26.34   $18.44   $26.77  
Medicare  $23.64   $23.64   $23.64   $23.64   $23.64  
Medicaid  $22.51   $21.73   $17.80   $23.21   $14.08  
84443   FEHB 1   $15.55   $15.65   $24.90   $15.55   N/A 
FEHB 2   $15.36   $15.36   $33.68   $15.36   $15.36  
FEHB 3   $7.95   $32.86   $28.16   $16.84   $24.53  
Medicare  $10.94   $10.94   $10.94   $10.94   $10.94  
Medicaid  $10.42   $10.06   $8.24   $6.00   $6.52  
85025   FEHB 1   $7.38   $7.38   $11.95   $7.67   N/A 
FEHB 2   $5.03   $5.03   $16.04   $5.03   $8.19  
FEHB 3   $3.68   $15.20   $13.37   $7.80   $11.35  
Medicare  $5.53   $5.53   $5.53   $5.53   $5.53  
Medicaid  $5.27   $5.08   $4.16   $4.00   $3.29  
85610   FEHB 1   $4.22   $4.22   $6.04   $4.22   N/A 
FEHB 2   $4.11   $5.12   $8.09   $5.12   $5.12  
FEHB 3   $5.13   $7.69   $6.74   $3.93   $5.74  
Medicare  $11.36   $11.36   $11.36   $11.36   $7.34  
Medicaid  $10.83   $10.44   $8.56   $8.00   $4.37  
87086   FEHB 1   $10.80   $24.50   $14.00   $24.50   N/A 
FEHB 2   $8.46   $9.59   $10.45   $10.45   $12.38  
FEHB 3   $10.16   $15.79   $11.57   $8.10   $7.61  
continued on next page 
 
   
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   39   
   
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS   State 
Insurer 
Code   SC  SD  TN  TX  UT 
Medicare  $11.91   $11.91   $9.71   $11.91   $11.91  
Medicaid  $10.63   $11.70   N/A  $11.64   $7.20  
80048   FEHB 1   $11.83   $13.01   $9.70   $9.58   $9.58  
FEHB 2   $7.56   $30.40   $19.08   $8.49   $5.19  
FEHB 3   $10.00   $14.50   $9.88   $5.50   $12.12  
Medicare  $13.45   $14.87   $12.13   $14.87   $14.87  
Medicaid  $12.01   $14.61   N/A  $14.53   $8.99  
80053   FEHB 1   $11.56   $20.68   $11.56   $11.56   $11.56  
FEHB 2   $6.19   $28.80   $20.49   $6.19   $6.19  
FEHB 3   $10.52   $18.00   $12.35   $8.80   $15.14  
Medicare  $13.79   $18.85   $18.85   $18.85   $18.85  
Medicaid  $12.31   $18.51   N/A  $18.42   $18.97  
80061   FEHB 1   $13.69   $26.21   $13.69   $13.69   $13.69  
FEHB 2   $8.20   $48.45   $29.00   $8.20   $8.20  
FEHB 3   $14.98   $23.00   $19.19   $11.15   $19.19  
Medicare  $4.44   $4.45   $4.45   $4.45   $4.45  
Medicaid  $3.96   $4.37   N/A  $4.36   $4.30  
81001   FEHB 1   $2.74   $14.73   $6.96   $2.74   $3.58  
FEHB 2   $4.52   $20.70   $10.93   $3.99   $2.78  
FEHB 3   $5.00   $5.50   $4.54   $3.36   $4.54  
Medicare  $3.60   $3.60   $3.60   $3.60   $3.60  
Medicaid  $3.22   $3.54   N/A  $3.51   $3.48  
81002   FEHB 1   $4.46   $4.49   $6.73   $4.39   $2.75  
FEHB 2   $3.57   $6.07   $9.15   $4.50   $2.24  
FEHB 3   $5.50   $4.50   $3.66   $2.38   $3.66  
Medicare  $3.16   $3.16   $3.16   $3.16   $3.16  
Medicaid  $2.82   $3.10   N/A  $3.09   $3.06  
81003   FEHB 1   $3.14   $4.50   $4.94   $3.00   $2.42  
FEHB 2   $3.47   $8.32   $6.20   $3.14   $1.97  
FEHB 3   $3.00   $4.00   $3.22   $2.09   $3.22  
Medicare  $41.66   $41.66   $41.66   $38.24   $41.66  
Medicaid  $37.17   $40.91   N/A  $37.36   $40.37  
82306   FEHB 1   $36.21   $43.88   $36.21   $36.21   $34.86  
FEHB 2   $58.01   $93.93   $59.50   $57.73   $57.73  
FEHB 3   $30.00   $51.00   $29.68   $22.96   $42.40  
Medicare  $7.28   $7.28   $7.28   $7.28   $5.78  
Medicaid  $6.50   $7.15   N/A  $7.11   $4.63  
82570   FEHB 1   $6.02   $7.55   $6.15   $6.02   $6.02  
FEHB 2   $10.14   N/A  $14.30   $13.03   $10.85  
FEHB 3   $6.28   $9.00   $7.41   $4.31   $5.88  
Medicare  $21.21   $21.21   $21.21   $21.21   $21.21  
Medicaid  $18.93   $20.83   N/A  $20.73   $20.55  
82607   FEHB 1   $16.03   $69.97   $16.65   $16.65   $16.03  
FEHB 2   $20.00   $47.70   $28.00   $19.71   $19.71  
FEHB 3   $20.00   $26.00   $21.59   $12.55   $21.59  
Medicare  $19.17   $19.17   $19.17   $19.17   $19.17  
Medicaid  $17.11   $18.83   N/A  $18.73   $18.59  
82728   FEHB 1   $15.03   $31.43   $20.19   $15.61   $15.07  
FEHB 2   $16.38   $21.24   $30.00   $16.38   $16.38  
FEHB 3   $9.50   $23.00   $19.51   $11.34   $19.51  
continued on next page 
 
   
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   40   
   
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS   State 
Insurer 
Code   SC  SD  TN  TX  UT 
Medicare  $13.66   $13.10   $13.66   $13.66   $13.66  
Medicaid  $12.19   $12.18   N/A  $13.34   $13.23  
83036   FEHB 1   $11.45   $20.25   $11.45   $11.45   $11.02  
FEHB 2   $12.35   $34.20   $22.81   $12.35   $5.95  
FEHB 3   $12.00   $16.00   $13.90   $8.08   $13.90  
Medicare  $9.12   $8.73   $9.12   $9.12   $9.12  
Medicaid  $8.14   $8.12   N/A  $8.91   $7.86  
83540   FEHB 1   $7.51   $9.00   $7.80   $7.80   $7.51  
FEHB 2   $5.12   $17.10   $14.00   $5.12   $5.12  
FEHB 3   $4.35   $10.50   $9.12   $5.48   $9.28  
Medicare  $12.30   $12.02   $12.30   $12.30   $12.30  
Medicaid  $10.98   $11.18   N/A  $12.02   $12.60  
83550   FEHB 1   $9.57   $8.85   $10.38   $9.95   $9.95  
FEHB 2   $12.28   $26.60   $20.00   $12.28   $10.38  
FEHB 3   $5.49   $14.50   $8.76   $7.39   $12.52  
Medicare  $47.77   $47.77   $47.77   $47.77   $47.77  
Medicaid  $42.62   $47.43   N/A  $46.68   N/A 
83880   FEHB 1   $45.87   N/A  $51.00   $45.87   $47.65  
FEHB 2   $44.45   $92.49   $98.00   $142.00   N/A 
FEHB 3   $42.75   $58.00   $42.75   $5.50   $48.62  
Medicare  $58.08   $58.08   $58.08   $58.08   $58.08  
Medicaid  $51.83   $57.04   N/A  $56.76   $56.29  
83970   FEHB 1   $45.27   $40.44   $46.15   $47.03   $45.27  
FEHB 2   $44.63   $117.00   $70.80   $44.63   $25.31  
FEHB 3   $37.49   $71.00   $41.38   $34.35   $59.12  
Medicare  $25.89   $25.89   $25.89   $25.89   $25.89  
Medicaid  $23.09   $25.42   N/A  $25.29   $25.70  
84153   FEHB 1   $18.73   $35.98   $18.73   $18.73   $18.73  
FEHB 2   $20.48   $56.79   $43.45   $20.48   $20.48  
FEHB 3   $30.00   $32.00   $26.34   $15.54   $26.34  
Medicare  $23.64   $23.64   $23.64   $23.64   $23.64  
Medicaid  $21.10   $23.21   N/A  $23.10   $22.91  
84443   FEHB 1   $16.16   $32.86   $16.16   $16.16   $15.86  
FEHB 2   $15.36   $48.60   $36.00   $15.36   $15.36  
FEHB 3   $15.03   $29.00   $24.06   $13.98   $24.06  
Medicare  $10.43   $10.94   $10.94   $10.94   $7.44  
Medicaid  $9.31   $10.74   N/A  $10.69   $6.66  
85025   FEHB 1   $10.36   $17.40   $17.11   $9.77   $7.38  
FEHB 2   $10.36   $26.08   $21.48   $9.77   $4.77  
FEHB 3   $9.77   $13.50   $11.14   $6.57   $7.57  
Medicare  $5.53   $5.53   $5.53   $5.53   $5.53  
Medicaid  $4.94   $5.43   N/A  $5.40   $5.37  
85610   FEHB 1   $5.49   $7.69   $8.44   $5.66   $4.34  
FEHB 2   $5.49   $23.63   $9.33   $6.00   $3.44  
FEHB 3   $6.00   $6.50   $5.62   $5.50   $5.62  
Medicare  $11.36   $11.36   $11.36   $11.36   $11.36  
Medicaid  $10.14   $11.16   N/A  $11.11   $9.22  
87086   FEHB 1   $24.50   $11.95   $24.50   $24.50   $16.50  
FEHB 2   $10.45   $28.05   $10.45   $10.45   $9.59  
FEHB 3   $10.04   $14.00   $10.04   $6.72   $11.57  
continued on next page 
 
   
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   41   
   
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS   State 
Insurer 
Code   VA  VT  WA  WI  WV  WY 
Medicare  $11.91   $11.91   $8.99   $11.91   $11.91   $10.82  
Medicaid  $11.12   $19.17   $6.95   $11.82   $10.72   $9.67  
80048   FEHB 1   $9.23   N/A  $11.07   $74.80   $15.15   $165.75  
FEHB 2   $4.98   N/A  $8.93   $74.80   $4.98   $4.98  
FEHB 3   $9.30   $17.90   $8.54   $13.94   $14.85   $16.00  
Medicare  $14.87   $14.87   $12.01   $14.87   $14.87   $14.87  
Medicaid  $13.88   $14.46   $9.29   $14.77   $13.38   $13.29  
80053   FEHB 1   $11.12   $10.34   $13.11   $58.20   $14.38   $15.14  
FEHB 2   $6.19   $11.25   $11.92   $56.25   $6.19   $6.19  
FEHB 3   $9.76   $23.97   $11.92   $17.41   $18.45   $30.00  
Medicare  $18.85   $15.45   $18.85   $18.85   $18.85   $15.67  
Medicaid  $17.58   $14.99   $14.58   $18.70   $16.97   $14.00  
80061   FEHB 1   $13.18   $10.74   $18.72   $74.46   $13.69   $19.51  
FEHB 2   $8.20   $14.35   $18.72   $99.45   $8.20   $8.20  
FEHB 3   $12.36   $29.33   $18.85   $30.32   $29.25   $32.00  
Medicare  $4.45   $4.45   $4.45   $4.45   $4.45   $3.60  
Medicaid  $3.76   $4.27   $3.45   $4.41   $4.01   $3.24  
81001   FEHB 1   $2.66   $19.74   $4.70   $28.05   $4.43   $3.66  
FEHB 2   $3.80   N/A  $4.63   $32.20   $3.80   $5.54  
FEHB 3   $3.50   $8.85   $4.43   $5.22   $5.40   $8.00  
Medicare  $3.60   $2.51   $3.60   $3.60   $3.31   $2.89  
Medicaid  $3.36   $2.44   $2.78   $3.57   $2.98   $2.58  
81002   FEHB 1   $2.14   $3.38   $6.00   $7.65   $3.29   $17.10  
FEHB 2   $2.14   $3.93   $3.57   $13.80   $6.11   $10.00  
FEHB 3   $3.15   $6.85   $3.60   $4.03   $4.50   $10.00  
Medicare  $3.16   $2.49   $3.16   $3.16   $3.16   $2.89  
Medicaid  $2.95   $2.35   $2.45   $3.13   $2.84   $2.60  
81003   FEHB 1   $2.19   $6.40   $3.77   $9.72   $3.33   $2.53  
FEHB 2   $2.67   N/A  $3.18   $23.80   $5.74   $11.32  
FEHB 3   $2.70   $6.80   $3.16   $3.84   $4.05   $4.00  
Medicare  $41.66   $41.66   $41.66   $41.66   $41.66   $41.66  
Medicaid  $35.67   $40.52   $32.22   $41.32   $37.49   $37.22  
82306   FEHB 1   $34.86   N/A  $36.88   $36.21   $43.88   N/A 
FEHB 2   $57.73   $57.73   $57.00   $105.45   $57.73   $57.73  
FEHB 3   $18.61   $46.21   $39.58   $42.40   $51.75   $53.00  
Medicare  $7.28   $7.28   $7.28   $7.28   $7.28   $7.28  
Medicaid  $6.79   $7.06   $5.63   $7.22   $6.55   $6.51  
82570   FEHB 1   $5.79   $6.47   $8.50   $10.85   $6.02   $6.02  
FEHB 2   $6.15   $7.67   $10.13   $25.30   $13.03   N/A 
FEHB 3   $5.70   $8.22   $6.92   $8.87   $9.00   $9.10  
Medicare  $21.21   $14.67   $21.21   $21.21   $21.21   $16.09  
Medicaid  $19.79   $14.21   $16.41   $21.04   $19.09   $14.38  
82607   FEHB 1   $16.65   $16.03   $21.59   $19.58   $21.06   $81.00  
FEHB 2   $19.71   $19.71   $21.06   $71.60   $19.71   N/A 
FEHB 3   $9.48   $22.03   $20.15   $23.75   $26.10   $21.59  
Medicare  $19.17   $19.17   $19.17   $19.17   $19.17   $19.17  
Medicaid  $17.89   $18.65   $14.83   $19.02   $17.25   $17.13  
82728   FEHB 1   $15.61   N/A  $20.19   $52.57   $19.17   $19.86  
FEHB 2   $16.38   N/A  $19.03   $140.60   $21.79   $16.20  
FEHB 3   $12.57   $25.03   $18.21   $42.86   $23.85   $29.27  
continued on next page 
 
 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   42   
   
Medicare CLFS, State Medicaid Program Fee Schedule, and 
FEHB Program Median Payment Rates for Selected Laboratory  
Test Codes (Continued)  
HCPCS   State 
Insurer 
Code   VA  VT  WA  WI  WV  WY 
Medicare  $13.66   $13.66   $13.66   $13.66   $13.66   $10.69  
Medicaid  $12.75   $13.25   $10.56   $13.55   $12.29   $9.55  
83036   FEHB 1   $11.02   $11.02   $14.00   $32.73   $13.80   $12.38  
FEHB 2   $12.35   $35.00   $13.56   $63.75   $12.35   $12.35  
FEHB 3   $10.50   $20.53   $13.66   $16.63   $17.10   $18.00  
Medicare  $9.12   $9.12   $9.12   $9.12   $9.12   $9.12  
Medicaid  $8.50   $8.80   $7.05   $9.04   $8.21   $8.15  
83540   FEHB 1   $7.80   N/A  $7.80   $24.00   $8.97   N/A 
FEHB 2   $5.12   N/A  $9.05   $37.96   $5.12   $2.10  
FEHB 3   $5.97   $13.69   $8.66   $10.67   $11.25   $9.32  
Medicare  $12.30   $12.30   $12.30   $12.30   $12.30   $12.30  
Medicaid  $11.48   $11.94   $9.52   $12.20   $11.07   $10.99  
83550   FEHB 1   $9.95   N/A  $9.95   $28.50   $12.30   N/A 
FEHB 2   $10.38   N/A  $12.28   $57.00   $16.00   $9.45  
FEHB 3   $8.06   $18.48   $11.69   $14.40   $15.30   $15.38  
Medicare  $47.77   $47.77   $47.77   $47.77   $47.77   $47.77  
Medicaid  $45.06   $26.14   $36.95   $47.43   $42.99   $42.69  
83880   FEHB 1   $45.87   N/A  $67.55   $180.24   $50.32   N/A 
FEHB 2   $87.73   N/A  $49.56   $122.88   $176.80   N/A 
FEHB 3   $42.75   N/A  $45.38   $52.29   $44.03   $36.00  
Medicare  $58.08   $58.08   $58.08   $58.08   $58.08   $58.08  
Medicaid  $54.19   $56.47   $44.93   $57.61   $52.27   $51.90  
83970   FEHB 1   $61.18   N/A  $66.35   $49.47   $58.08   N/A 
FEHB 2   $44.63   N/A  $57.67   $263.15   $95.00   $44.63  
FEHB 3   $31.72   $87.27   $55.18   $59.12   $72.00   $73.90  
Medicare  $25.89   $25.89   $25.89   $25.89   $25.89   $25.89  
Medicaid  $23.28   $20.92   $20.02   $25.67   $23.30   $23.13  
84153   FEHB 1   $18.03   N/A  $27.26   $77.52   $18.73   $26.34  
FEHB 2   $20.48   $28.79   $25.70   $114.75   $20.48   $54.00  
FEHB 3   $16.98   $38.89   $24.60   $39.51   $31.95   $40.00  
Medicare  $23.64   $23.64   $23.56   $23.64   $23.64   $23.09  
Medicaid  $22.05   $22.92   $18.22   $23.44   $21.28   $20.64  
84443   FEHB 1   $16.16   $26.97   $24.90   $93.50   $21.93   $28.75  
FEHB 2   $15.36   $26.39   $21.81   $105.40   $15.36   $15.36  
FEHB 3   $15.51   $29.34   $22.38   $28.78   $29.25   $36.09  
Medicare  $10.94   $10.94   $10.94   $10.94   $10.94   $10.94  
Medicaid  $10.00   $10.63   $8.47   $10.85   $9.85   $9.85  
85025   FEHB 1   $7.67   $7.60   $12.10   $52.70   $11.19   $13.62  
FEHB 2   $5.03   $10.86   $10.86   $60.35   $5.03   $18.78  
FEHB 3   $8.50   $16.43   $10.94   $12.81   $13.50   $24.00  
Medicare  $5.53   $5.53   $5.53   $5.53   $5.53   $4.47  
Medicaid  $5.16   $5.32   $4.27   $5.48   $4.98   $4.00  
85610   FEHB 1   $4.22   $7.18   $5.93   $25.22   $5.49   $18.22  
FEHB 2   $4.67   $22.53   $6.00   $57.00   $8.15   $17.76  
FEHB 3   $4.95   $8.30   $5.53   $6.46   $6.75   $8.00  
Medicare  $11.36   $8.12   $11.36   $11.36   $11.36   $5.29  
Medicaid  $9.50   $7.84   $8.79   $11.27   $10.22   $4.76  
87086   FEHB 1   $26.16   $28.56   $20.70   $59.50   $12.49   $8.68  
FEHB 2   $9.59   N/A  $11.28   $58.50   $10.45   $10.45  
FEHB 3   $10.13   $12.19   $10.79   $13.31   $13.95   $8.25  
Source:  Office of  Inspector General analysis of Medicare CLFS, State Medicaid Program, and FEHB plan payment rates, 2012. 
 
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   43   
   
APPENDIX D 
Potential Savings to Medicare 
Number 
2011  2011  of Tests  Amount of 
Percentage 
HCPCS*  Number of   Medicare- With  Potential 
Description   Savings to 
Code26   Allowed  Allowed  Potential  Savings to 
Medicare 
Tests  Amount  for  Medicare  
Savings 
Metabolic panel, total 
80048    8,870,790  $87,715,544   7,537,056   $36,412,622   42%  
calcium 
Comprehensive 
80053   27,406,336   $315,878,919  24,785,107   $130,632,849   41%  
metabolic panel 
80061   Lipid panel  20,620,917   $300,263,670  18,497,996   $125,993,031   42%  
Urinalysis, automated, 
81001    6,804,619  $30,263,393   6,406,217   $9,801,294   32%  
with microscopy 
Urinalysis, 
81002   nonautomated,   4,312,499  $15,380,015   4,045,779   $4,427,415   29%  
without microscopy 
Urinalysis, automated, 
81003    5,078,609  $16,012,775   4,673,129   $4,383,224   27%  
without microscopy 
82306   Vitamin D, 25 hydroxy  5,394,421   $221,597,882  5,343,831   $87,398,016   39%  
Assay of urine 
82570   4,649,643  $33,541,369   4,616,456   $10,457,972   31%  
creatinine 
82607   Vitamin B-12  3,363,543  $71,298,574   3,329,444   $25,252,596   35%  
82728   Assay of ferritin   2,401,360  $45,904,070   2,309,044   $15,613,616   34%  
Glycosylated 
83036   12,678,817   $172,653,909  12,377,783   $51,406,983   30%  
hemoglobin test 
83540   Assay of iron   2,625,017  $23,249,999   2,511,258   $10,256,188   44%  
83550   Iron binding test   2,043,112  $24,606,097   2,020,049   $9,228,580   38%  
83880   Natriuretic peptide  1,079,558  $50,927,315   1,054,424   $15,970,434   31%  
Assay of 
83970    1,154,872  $67,030,516   1,143,748   $22,934,465   34%  
parathormone 
Assay of prostate-
84153   3,616,338  $93,492,483   3,545,187   $32,784,887   35%  
specific antigen, total 
Thyroid stimulating 
84443   14,761,102   $348,014,395  14,465,072   $140,148,947   40%  
hormone 
*Healthcare Common Procedure Coding System.  continued on next page 
 
   
 
26  HCPCS Level 1 numerical codes are identical to CPT codes and are used by CMS 
when services  and procedures involve  Medicare beneficiaries (e.g.,  70405).  The five  
character codes and descriptions included in this report are obtained from Current 
Procedural Terminology (CPT), copyright 2011 by the  American Medical 
Association (AMA).  CPT is developed by the AMA as a listing of descriptive terms  
and five character identifying codes and modifiers for reporting medical services 
and procedures.  Any use of CPT  outside of this report should refer to the most  
current version of the Current Procedural  Terminology available from 
AMA.   Applicable FARS/DFARS  apply.  
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   44   
   
Potential Savings to Medicare (Continued) 
Number 
2011  2011  of Tests  Amount of 
Percentage 
HCPCS   Number of   Medicare- With  Potential 
Description   Savings to 
Code   Allowed  Allowed  Potential  Savings to 
Medicare 
Tests  Amount  for  Medicare  
Savings 
Complete blood count 
with automated 
85025    30,827,609   $333,380,573  29,163,289   $136,848,356   41%  
differential white blood 
cell count 
85610   Prothrombin time   20,291,205   $111,952,080  18,942,447   $24,637,107   22%  
Urine culture colony  
87086   4,703,518  $53,236,384   4,642,330   $15,296,087   29% 
count 
    Total   182,683,885   $2,416,399,964   171,409,646   $909,884,674   38%  
Dollar amounts are  rounded to the nearest $1. 

Source:  Centers for Medicare & Medicaid Services, National Claims History  Part B Carrier File, 2012.  

 
   
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   45  APPENDIX E 
Agency Comments 
Centers tor Medicare & Medicaid Services 
------------
Administrator 
Washington, DC 20201 
APR 2 6 2013
DATE: 
TO:  Daniel R. Levinson 
Inspector General 
FROM:  Matil;rn "':avenner 
Actilllg Ad'ministrator 
SUBJECT:  Office M' IJY;pector General (DIG) Draft Report: Comparison of Laboratory Test 
Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-I 1-000 I0) 
Thank you for the opportunity to review and comment on this OlG draft report. 1be Centers for 
Medicare & Medicaid Services (CMS) appreciates OIG 's effort to examine the laboratory 
payment rates for different payers. OIG collected payment data from 50 state Medicaid 
programs and three Federal Employees Health Benefits (FE! !B) plans that pay for laboratory 
tests on a fcc-for-service basis. OIG requested the payment rates for 20 laboratory tests and for 
each test compared Medicare paid claims with the state Medicaid program fee schedule amount 
and FEHB plan median claim payment amounts. State Medicaid programs and FEHB plans 
were surveyed to determine how their laboratory test fee schedules or payment rates were 
formulated, whether a copayment was charged to the patient, and whether laboratory test charges 
counted towards a member's deductible. 
The OIG found that in 20 II, Medicare paid between 18 and 30 percent more than other insurers 
for 20 high-volume and/or high-expenditure laboratory tests.  State Medicaid programs and 
FEHB plans usc the Medicare clinical laboratory fee schedule as a basis for establishing their 
0\1\>n fee schedules and payment rates, although most pay Jess.  However, unlike Medicare, FEHB 
programs incorporate factors such as competitor information, changes in technology used in 
perfom1ing laboratory tests, and provider requests in their payment rates.  Some state Medicaid 
programs and FEHB plans required copayments for laboratory tests which, in effect, lowered the 
costs oflaboratory tests for the insurer. CMS's responses to OIG's recommendations arc 
discussed below. 
OJG Recommendation I 
The 010 recommends that CMS seek legislation that would allow CMS to establish lower 
payment rates for lab tests. 
CMS Response 
The CMS appreciates OIG's recommendation and the valuable work reflected in this report. 
CMS is currently exploring whether it has authority under the current statute to revise payment~ 
for clinical diagnostic laboratory services consistent with the OIG's recommendation. 
Comparing Lab Test Payment Rates: Medicare Could Achieve Substantial Savings (OEI-07-11-0001 0)  47   
   
Agency Comments (Continued) 
   
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)  47   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Brian T.  Whitley, Acting 
Regional Inspector General for Evaluation and Inspections in the Kansas 
City regional office. 
Tricia Fields served as the team leader for this study.  Other Office of 
Evaluation and Inspections staff from the Kansas City regional office who 
conducted the study include Michael P.  Barrett and Teresa Dailey.  Other 
regional and central office staff who contributed include Kevin Farber, 
Scott Horning, Scott Manley, Brian Pattison, Debra Roush, and Mandy 
Walz.  
Comparing Lab Test Payment Rates:  Medicare Could Achieve Substantial Savings (OEI-07-11-00010)   48   
   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and abuse cases involving HHS programs,  including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.