Solid reporting from all applicable laboratories is the key to mitigate future PAMA fee schedule cuts. This means labs need to be able to report on actual allowables vs. payments, validate the accuracy of payments, and optimize appeals activity to avoid under-reporting payments. All applicable labs are included in the current data collection period now under way for first half of 2019.
To properly prepare for the next PAMA reporting period the first step must be to confirm your applicable lab status. In order to be considered an applicable lab, labs must meet the following criteria as of January 1, 2019 (see CMS Rules for reference):
Clinical Laboratory Improvement Amendments (CLIA) certifiedBills under own national Provider Identifier (NPI) or he 14x bill type Meets new majority of Medicare revenues threshold, which excludes Part C (Medicare Advantage) – see calculation below
Exceeds low expenditure threshold of 12,500 in the revenue during data collection period
Once you have confirmed your lab’s applicable status the next logical step in your preparation should be ensuring your revenue cycle management solution (RCM) can provide the required details. Here are some keys to consider when executing your RCM data review:
RCM system must routinely capture data to:
Consolidate multiple payments per procedure code and adjusted allowablesReconcile units billed vs. paid Identify paid claims still in process, including appeals, redetermination, corrected claims, etc.Identify over payments and under paymentsAccurately process recoupments, refunds and adjustments at the procedure code level
Capture components of contractual allowance calculation
RCM systems must also be able to capture:
Date(s) paidPayor/payor typeNumber of tests for each procedure codeNumber of units billed vs. paid for each procedure codeAmount allowed and its components: $ paid by insurer plus patient share of costAdjustments that impact the contractual rates (e.g., sequestration)Aggregate data in timely buckets (e.g., payments received 1/1/19 - 6/30/19)Recoupments, refunds and adjustments
Partially paid tests
Now that you have made sure your system is up to par, the same needs to be done for your personnel. Creating a project team to prepare for data submission should be your third step in the preparation process. Be sure to assign authority to a project leader who will sign off on a final submission. This project lead should designate individuals for data collection and review, including:
Financial analystFinancial/Compliance auditorBilling system and reimbursement expert
IT or reporting expert with access to reporting tools and source data
So far we’ve covered the first three steps in preparing for PAMA reporting, but there are a few more crucial steps to this process. Stay tuned for the remaining steps in next week’s blog post.
Want more information on how to prepare for PAMA? Take a look at this recent Executive War College presentation by XIFIN Financial Analyst, Craig Young titled: Key Recommendations for PAMA Reporting