June 30, 2019 marked the end of the first data collection period under the Protecting Access to Medicare Act (“PAMA”). If you are a qualifying laboratory you should be starting the analysis of this data with the intent to submit during the first quarter of 2020. Failure to submit the data pursuant to CMS guidelines may lead to Civil Monetary Penalties up to $10,000 per day of noncompliance. Are you prepared to submit the applicable data?

PAMA established a reporting system that will use laboratory payment data from applicable laboratories to develop the new Clinical Lab Fee Schedule private payer rates. Data submission is required every three years, beginning January 2020. However, the data to be submitted for the first round of reporting is based upon claims data submitted between January 1, 2019 and June 30, 2019.  CMS expects providers to submit service line level data, which includes the specific payment rate for each applicable HCPCS code from each private payer within the sixth month data collection period.

CMS provides the following guidelines for laboratories:

  • January – June, 2019: Collect data
  • July – December, 2019: Analyze data
  • January – March, 2020: Report data

The reporting requirements only apply to certain lab service providers, as designated by CMS. The two types of laboratories that must adhere to the reporting requirements are:

  1. A CLIA certified lab that bills under its own NPI; and
  1. A hospital-based CLIA certified outreach lab billing under the hospital’s NPI
    1. Please note: this only applies to lab services rendered to non-hospital patients (typically billed on a TOB 14x)

If your facility offers lab services under either category, Advis is available to assist in reviewing specific claims data to confirm whether the facility meets the additional thresholds that would trigger the full reporting requirements, including: (1) the majority of Medicare revenues threshold, and (2) the low expenditure threshold.

Once confirmed that your facility is an applicable laboratory, Advis can assist with organizing the complex data into the required CMS template for upload into the CLFS Data Collection System during the reporting period.

For More Information, Please Call Our Office at (708) 478-7030 or Contact Us.