By Kelly A. Briganti, Editorial Director, G2 Intelligence
The Centers for Medicare & Medicaid Services (CMS) will publish a proposed rule in the Oct. 1 Federal Register implementing the Protecting Access to Medicare Act of 2014 (PAMA) and requiring Applicable Laboratories to report private payer reimbursement data regarding laboratory testing.
Applicable Laboratories would be those receiving at least $50,000 under the Clinical Laboratory Fee Schedule and “more than 50% of Medicare revenues from laboratory and physician services.” Such laboratories would need to report private payer payment rates and volume of services. If an organization includes multiple facilities, not just laboratories, that 50% threshold is calculated based on the Medicare revenue for the entire organization—so the organization must receive more than 50% of its entire revenue for all components, not just its laboratories, from payments under the Clinical Laboratory Fee Schedule and Physician Fee Schedule.
In a Fact Sheet released late last week, CMS reports: “We do not expect hospital laboratories to meet the definition of applicable laboratory, and we estimate that more than 50 percent of independent laboratories and more than 90 percent of physician offices will be precluded from reporting private payer data under the low expenditure criterion.” However, CMS still predicts that “physicians and laboratories that would be required to report account for 96 percent of CLFS spending on physician office laboratories and more than 99 percent of CLFS spending on independent laboratories.”
Reported data will be from the period July 1, 2015 through Dec. 31, 2015. Reports are due by March 31, 2016 and CMS promises new Medicare rates will be released Nov. 1, 2016 to be effective Jan. 1, 2017.
The proposed rule indicates “to be assured consideration” comments must be received by 5 p.m. on Nov. 24, 2015. We will provide more in-depth coverage of the proposed rule in upcoming issues of Laboratory Industry Report and National Intelligence Report.