Healthcare laboratories that rely on reference lab relationships may need to reevaluate their reimbursement strategies following a new reimbursement policy from Anthem. Beginning December 1, 2026, the policy clarifies that laboratory tests performed by a reference laboratory must be billed by the laboratory that performed the service, eliminating reimbursement for pass-through billing using Modifier 90.
For many independent and regional laboratories, this change could have significant financial implications. Historically, some laboratories collected specimens, sent testing to a reference laboratory, and billed the payer directly. Under the new guidance, reimbursement will be directed to the laboratory that performs the test.
What Laboratories Need to Know
Key considerations include:
- Professional and outpatient facility claims billed with Modifier 90 will no longer be eligible for reimbursement under the new policy.
- The laboratory performing the test must submit the claim and receive reimbursement directly.
- Laboratories that routinely send tests to reference labs may experience changes to reimbursement workflows and revenue streams.
- Existing reference laboratory agreements may need to be reviewed and updated.
- Organizations may need to evaluate whether to expand in-house testing capabilities, renegotiate reference lab relationships, or absorb collection and handling costs as part of their service model.
Potential Business Impact
The policy change could affect laboratories that serve as specimen collection sites but do not perform all testing internally. As reimbursement shifts to the performing laboratory, organizations may need to reassess:
- Reference laboratory partnerships
- Revenue cycle processes
- Client retention strategies
- Cost recovery models for specimen collection and logistics
- Investments in new testing capabilities
For some laboratories, send-out testing may increasingly become a cost of maintaining client relationships rather than a direct revenue opportunity.
Affected Plans and Markets
The reimbursement update applies across multiple Anthem and Elevance Health markets, including Medicare Advantage, Commercial, and Medicaid lines of business in several states. Published policy notices include Ohio, Wisconsin, California, Indiana, Kentucky, Missouri, New York, and Colorado, with additional Anthem markets expected to follow the same reimbursement approach.
Looking Ahead
As laboratories prepare for implementation, understanding the operational and financial impact of this policy will be critical. Organizations should review reference testing workflows, evaluate reimbursement exposure, and ensure revenue cycle processes align with the new billing requirements before the December 2026 effective date. For Quadax clients, please contact your Account Executive.
