Provider Payment Rate changes for Clinical Labs (Public hearing scheduled for July 3, 2014 in Boston)

The proposed amendments revise the payment rates for clinical laboratory services and make conforming changes to certain defined terms. Under the regulation, the rates are benchmarked against Medicare rates. For 1,242 rates, the rates are set at 74.67% of the 2014 Massachusetts Medicare clinical lab rates, with inflation of 0.306% for the first rate period and .916% for the second rate period. The proposal significantly lowers rates for BRCA genetic testing because Medicare is now paying for these tests, and pays a significantly lower amount than the current published fee schedule rate. The proposal clarifies, but does not substantively change the reference to the federal upper payment limit for laboratory tests in 101 CMR 320.04(1)(c). Most rates have decreased -$0.56 (-4.57%) for the first rate period and -$0.45 (-3.67%) for the second rate period, relative to their current rates. The BRCA rates have decreased by approximately $1,654.00 (80%). Some codes were not set by discounting the Medicare rate; they were priced by either: (1) applying inflation to the current rates; (2) maintaining the current rates; or (3) designating the code as requiring “individual consideration,” which is a procedure used to price certain codes on a case-by-case basis. The amendments are proposed to become effective August 1, 2014.