CMS Requires some Hospital Clinical Diagnostic Laboratories to Collect and Report Private Payor Rates

January 16, 2019

Section 216 of the Protecting Access to Medicare Act of 2014 (PAMA), requires certain clinical laboratories to collect and provide the Centers for Medicare and Medicaid Services (CMS) information regarding commercial payor rates for purposes of calculating the Medicare Clinical Lab Fee Schedule.  Effective January 1, 2019, hospitals that provide outreach laboratory services to other than hospital patients may need to report to CMS payment rates and volumes for those services.  Lab services for hospital patients are not subject to reporting as they are paid under the hospital payment methodology rather than the laboratory fee schedule.

According to the Clinical Diagnostic Test Payment System final rule, a hospital must submit data for outreach laboratories that bill using a 14X type of business, have more than $12,500 in Medicare revenues from laboratory services on the Clinical Laboratory Fee Schedule (CLFS), and receive more than 50 percent of their Medicare revenues from CLFS and physician fee schedule services during a data collection period. Laboratories that meet these criteria must collect private payor data from January 1, 2019 through June 30, 2019 and report it to CMS by March 31, 2020. The data will be used to determine the CY 2021 lab fee schedule.

CMS is offering a webinar at 11:00 am, January 22 to provide more information regarding the reporting requirements. Interested parties must register for the webinar here. Additional information can be found on the PAMA Regulations webpage. (Andrew Busz,


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