PAMA: The Nitty Gritty on Labs Affected & What’s Required

As labs prepare for 2019, it is important to understand what has taken place this past year, and what is to come in order to move forward amicably without hitting the same barriers and roadblocks presented by PAMA in 2016. As you can see in the chart below hospital = outreach and physician office laboratories (POLs) were underrepresented in 2018 making solid reporting a key to mitigating future price cuts going forward, especially with the second round of PAMA cuts having the potential to cut individual test payments by up to 15% per year.

Laboratories should keep these three factors in mind when it comes to reporting:

• Report on actual allowables verses payments
• Validate the accuracy of a payment
• Optimize appeals activity to avoid reporting under payments

One of the biggest changes set to impact labs is the redefinition of applicable labs, expanding the number of reporting labs to include smaller labs and hospital labs like independent and outreach labs. This change is set to include most hospital labs in the data collection period now underway for the first half of 2019.

For every CLFS test going forward, laboratories will be required to report “applicable information” which includes:

• Specific procedure code for each test
• Each rate and each private payor allowed for that test
• Volume at each private-payor rate

Labs will not be required to report the following:

• Any test for which payment is made on a capitated basis
• Tests subject to an unresolved appeal
• Tests with the final payment of zero dollars (because payor refused to pay)
• Tests where the payor groups multiple tests together in claim-level payment so lab cannot correlate code payment
• Tests coded with an “unlisted” CPT code or a “not otherwise classified” HCPCS Level II code

Recently, Lâle White, CEO and Executive Chair, XiFin covered PAMA in a hospital outreach laboratory specific webinar. Click below to listen to the full webinar: