Reimbursement under costs for lab test

As we head into winter, I’m looking at some of the underpayments within my office. For example RSV tests are getting reimbursed at half of my cost to purchase the kit: cost of test $15.02, reimbursement $10-13. I am not willing to hemorrhage money for underpayment any longer, especially when we are the a huge contribution to children returning to school and parents returning to work. Yet every school and daycare algorithm requires I exclude a COVID by testing or diagnose with alternative such as RSV, Flu or strep.
Does anyone have a strong letter for contract review of CPT underpayments and/or tips to get this quickly handled?
Thanks, Kristi Machemer, MD


We are experiencing the same problem with COVID test 87635. 2 InsCos refused to negotiate even based on pricing lists and invoices. We will not perform these test in house for those payers.

Pediatrics in Brevard

Hi Victoria! Welcome to the forum! Missed seeing you all at the UC this year!!! Hope you are all well!-

We are having the same problem here too. Mainly with the Covid 87426. I assumed this was because CMS had released this code for use but had not added a fee yet. Probably naïve of me to think this might get better?

Same here, Covid test 87635 for Ohio Medicaid pays $35.92 and our cost is $41-42 per test. We are 60% Medicaid, private practice, can’t afford to NOT do the test as Urgent Care across the street will do it if we won’t do it then we lose the patients. Would LOVE something to send to Medicaid to update the fee schedule to cover our costs…

We are reimbursed and make a small profit for most insurance companies with the exception of UHC for Covid Testing - but only if we bill G2023 for collection and handling. All insurance companies have reimbursed collection and handling except BCBS. Their reasoning is because that is only reimbursed to lab providers, which makes no logical sense to me.

We’re only performing rapid flu a/b and rapid strep in the office. RSV and COVID 19 are send out tests to local lab with results available in 48 - 72 hours. We will obtain the nasal swab in our office and hope for the payment of cpt 99000 associated. The financial outlay and loss associated with the latter are cost prohibitive as we are 60+% medicaid, not to mention the PPE etc needed. Be well. Be safe!