HIV Testing and Screening Cost and Reimbursement

A Package of Tools for Providers to Improve Quality of Care and Maximize Reimbursement

Introduction

The Centers for Disease Control and Prevention (CDC) recommends routine HIV screening of all adults, regardless of risk. A critical part of developing and sustaining a screening program is integrating it into the mission of the organization in a financially prudent manner.

In addition to the CDC guidelines, the U. S. Preventive Services Task Force (USPSTF) gives an "A" recommendation for screening patients who are at risk for HIV, as well as any patient who requests a test.  Several clinical specialty societies also support routine screening.

This package of information on HIV testing and screening, including cost and reimbursement tools, assists clinical managers and individual practitioners in starting or expanding an HIV screening or diagnostic testing program.  The scope of these resources is limited to screening and testing, and does not explore linkage-to-care issues.

Who Should Use This Guide

This information is designed for health care providers who are not necessarily experts on HIV, finance or reimbursement, and serves as a guide to asking the right questions in each health system, hospital or clinic.  Because each provider is different, it is difficult to present precise cost and reimbursement information specific to each organization.  However, the broad list of issues presented serves as a framework for further research and discussion in an institution.  The information is relevant to for:

• Primary care clinics
• Inpatient units
• Emergency departments
• Specialty clinics
• Physician offices
• Ancillary services
• Outpatient services

HIV in the United States

The CDC estimates:

• One in five of the 1.1 million Americans infected with HIV does not know it. 
• Some 56,000 new infections occur annually.
• HIV infections are often detected late, after the person has become noticeably ill. Within 12 months, these individuals' HIV status progresses to AIDS. In many cases, the patients had previous encounters with the health care system, but were never tested for HIV.
• Some 25% of HIV-infected persons who are unaware of their status account for upwards of 70% of the new HIV transmissions.

CDC  and USPSTF Recommendations

In part, the CDC recommends routine, voluntary HIV screening for:

• All persons 13-64 in healthcare settings, not based on risk
• All patients with TB and those seeking treatment for STDs
• Repeat HIV screening of persons with known risk at least annually

For a complete list of CDC's recommendations, go to Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. In addition, CDC offers resources for primary care providers here.

For the USPSTF recommendations, go to Screening: Human Immunodeficiency Virus.

Definitions

• Diagnostic testing: Performing an HIV test for persons with clinical signs or symptoms consistent with HIV infection.
• Screening: Performing an HIV test for all persons in a defined population.

This Package Includes

The tools in this package of cost and reimbursement materials include:

• A summary of key issues, questions and resources
• A chart highlighting which payers reimburse for testing and screening
• A basic cost calculator to estimate expenses and revenue

Contact Information

For more information, contact Awo Osei-Anto, Researcher, Health Research & Educational Trust, hanto@aha.org or (312) 422-2642.

Acknowledgement

This resource is made possible through funding from the Center for Disease Control and Prevention; National Center for HIV/AIDS, STD and TB Prevention, Division of HIV/AIDS Prevention, through Cooperative Agreement Number 5U65PS000818-04. Its content are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.

Suggested Citation

Miller, J; Hund, C; Akamigbo, A; HIV Testing and Screening Cost and Reimbursement Toolkit. www.hret.org/hiv-cost accessed on date