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The First Steps in Preparing for the PAMA Reporting Period (Part 1)

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 underway for the first half of 2019.

Step 1: Status Confirmation

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) certified
  • Bills 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

Step 2: RCM Data Review

Once you have confirmed your lab’s applicable status the second 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 allowables
  • Reconcile units billed vs. paid
  • Identify paid claims still in process, including appeals, redetermination, corrected claims, etc.
  • Identify over payments and under payments
  • Accurately 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) paid
  • Payor/payor type
  • Number of tests for each procedure code
  • Number of units billed vs. paid for each procedure code
  • Amount allowed and its components: $ paid by insurer plus patient share of cost
  • Adjustments 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

Step 3: Project Team

Now that you have made sure your system is up to par, the same needs to be done for your personnel. The third step is 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 final submission. This project lead should designate individuals for data collection and review, including:

  • Financial analyst
  • Financial/Compliance auditor
  • Billing 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. Check out part 2 of this blog series titled: Final Steps in Preparing for the PAMA Reporting Period (Part 2).

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

Published by XIFIN
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