On June 23, 2016, the Centers for Medicare & Medicaid Services (CMS) released a Final Rule implementing Section 216 of the Protecting Access to Medicare Act of 2014 (PAMA), requiring laboratories performing clinical diagnostic laboratory tests to report the amounts paid by private insurers for laboratory tests. Medicare will use these private insurer rates to calculate Medicare payment rates for laboratory tests paid under the Clinical Laboratory Fee Schedule (CLFS) beginning January 1, 2018.1
The Final Rule not only reforms reimbursement for clinical laboratory testing but also has numerous requirements and components that laboratories need to understand and comply with. Noncompliance with these new requirements can have financial impacts on the laboratory/institution. Defined within the legislation are elements such as:
- Definition of applicable laboratories required to report to CMS
- Reporting periods, applicable information to be reported, and designated reporting authorities
- Definition of advanced diagnostic laboratory tests (ADLTs) and how they differ in reporting and rate setting
This presentation will address important provisions of the law, including the new data reporting responsibilities for applicable laboratories, details about and timeframes for reporting private payer information, and information on the annual rate reductions allowed under the legislation. The presentation will also help laboratories translate the Final Rule to identify required actions and potential impacts for their laboratories.
1 PAMA Regulations, CMS, September 19, 2016