FEE SCHEDULES

How PAMA’s Effect in 2018 Molecular Diagnostic Reimbursement Will Make Labs More Money

By Sean McSweeney  bio

The year 2018 is slated to be much brighter for molecular diagnostic labs as PAMA fee schedules show a higher payment rate and amount for many cancer genomics and pharmacogenetics tests.

Generally, reimbursement rates have increased across the board for advanced molecular testing.

For instance, code 81298 (MLH6 gene analysis full sequence) averaged a CMS projected reimbursement of $289.41 in 2017.

However, in 2018 the average for this code’s reimbursement has jumped up to $641.85.

Pushback from companies that produce these tests has facilitated a much higher payment rate from Medicare.

Another reason this bodes well is that private and secondary payers that usually follow the Medicare payment guidelines are projected to pay higher.

As PAMA continues to be felt by U.S. labs, advanced testing is experiencing a much higher reimbursement.

PAMA In 2018

PAMA’s implementation of a market-based payment system back in 2014, while met with mixed reviews over the years, is seeing some more positive response here from labs.

Under this adjustment in 2018, localities have been done away with, so the payment rates stay consistent across the U.S., and, as the payments are based on this weighted median, the law mandates that there can be no payment reduction of over 10% in the first three years.

Furthermore, no payment can be reduced by 15% in the following 3 years after the initial 3 have passed.

While labs have been pushing back on PAMA’s ability to establish a fairly encompassed market on which to base pricing, the reimbursements have been high for advanced tests.

Below are just three of the many improved reimbursement averages on CGx and PGx codes.

CODE DESCRIPTION 2017 REIMBURSEMENT AVERAGE 2018 REIMBURSEMENT AVERAGE
81292 MLH1 gene analysis full sequence analysis $649.78 $675.40
81295 MLH2 gene analysis full sequence analysis $152.54 $381.70
81298 MLH6 gene analysis full sequence analysis $289.41 $641.85

The Overall Impact on Your Lab

While PAMA’s effect on 2018 is still questioned, molecular diagnostics and advanced diagnostic tests are earning much higher reimbursement rates than previous years.

This indicates one thing for your molecular diagnostic lab: more money.

Keep an eye out for these rising trends on advanced tests for your lab and capitalize on this opportunity.


(-00000g2)