CMS Outlines PAMA Reporting Requirements

In late July, the Centers for Medicare and Medicaid Services (CMS) released the first of several guidance documents to assist clinical laboratories in implementing the Protecting Access to Medicare Act (PAMA), which rebases the clinical laboratory fee schedule (CLFS) to reflect private sector fees.  Initially, the new payment rates were to take effect on January 1, 2017; however, delays in drafting the regulation pushed the start date back until January 1, 2018.  Before the implementation date, “applicable” laboratories will be required to report private sector volume and payment rates to the agency.

The CMS guidance states that there are four criteria that determine whether a laboratory has to submit private sector data to the agency:

• The laboratory is certified under CLIA;
• The laboratory bills Medicare under a separate national provider identifier (NPI);
• The laboratory receives 50 percent or more of its Medicare revenues from payments under the CLFS or physician fee schedule (PFS); and
• It receives at least $12,000 in Medicare revenues from the CLFS for the reporting period.

The agency states that laboratories should not report any price concessions given to a patient, unresolved appeals or capitated payments.  CMS currently projects that “applicable” laboratories will begin reporting data January 1, 2017 covering the period of January 1, 2016 through June 30, 2016.  The rebasing process will take place every three years.   CMS has also developed a frequently asked questions document that addresses many concerns raised by laboratorians.