The Centers for Medicare & Medicaid Services (CMS) recently published a major final rule that will base Medicare clinical laboratory fee schedule (CLFS) reimbursement on private insurance payment amounts, as required by the Protecting Access to Medicare Act of 2014 (PAMA). In the coming year, “applicable laboratories” will have to report to CMS the private payor rates made to them during a specified six-month data collection period for this year. Among other important changes from the proposed rule, CMS will implement the new payment policy beginning January 1, 2018, rather than in 2017. This alert provides a summary and analysis of major provisions of the rule, including the rule’s complex new payment methodology, and a checklist of pending issues for which labs should be alert.
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