New requirements for Physician Office Based Laboratories reporting by CMS
The Centers for Medicare & Medicaid Services (CMS) has released a list of codes describing laboratory testing services for which laboratories, including Physician Office Based Laboratories, will be required to report pricing data starting Jan. 1. This new reporting requirement is part of CMS’ implementation of the Protecting Access to Medicare Act (PAMA) of 2014.
Under PAMA, Physician Office Based Laboratories meeting certain Medicare revenue thresholds will be required to report private payer payment rates for all laboratory tests included on the Clinical Laboratory Fee Schedule to CMS.
These Physician Office Based Laboratories meeting the threshold requirements are required to report private payer payment rates for the period from Jan. 1, 2016 to June 30, 2016, starting on Jan. 1, 2017.
The Clinical Laboratory Fee Schedule (CLFS) final rule entitled ?Medicare Program: Medicare Clinical Diagnostic Laboratory Tests Payment System? (CMS-1621-F) went on display in the Federal Register on June 17, 2016. The final CLFS rule implements section 216 of the Protecting Access to Medicare Act of 2014.
Under the final rule, laboratories and physician offices are required to report private payor rate and volume data if they have more than $12,500 in Medicare revenues from laboratory services on the CLFS and they receive more than 50 percent of their Medicare revenues from laboratory and physician services during a data collection period. Laboratories will collect private payor data from January 1, 2016 through June 30, 2016 and report it to CMS by March 31, 2017. CMS will post the new Medicare CLFS rates (based on weighted median private payor rates) in November 2017 that will be effective on January 1, 2018.
Tests that meet the criteria for being considered new advanced tests will be paid at actual list charge during an initial period of three calendar quarters. Once the initial period is over, payment for new advanced tests would be based on the weighted median private payor rate reported by the single laboratory that performs the new ADLT. Advanced tests are tests that are furnished by only one laboratory that include a unique algorithm and, at a minimum, are an analysis of RNA, DNA or proteins or are cleared or approved by the U.S. Food and Drug Administration (FDA).