New Resources Clarify Reporting Requirements for Hospital Outreach Laboratories

Posted on March 06, 2019

Effective Jan. 1, 2018, the Protecting Access to Medicare Act (PAMA) of 2014 requires that Medicare payment rates be based on the national weighted median of private payer rates reported by certain “applicable laboratories.” The Centers for Medicare & Medicaid Services (CMS) recently released updated resources to clarify whether a hospital outreach laboratory is an “applicable laboratory” subject to the reporting requirements established by the PAMA.

The resources incorporate changes for clinical laboratories made in the Medicare clinical laboratory fee schedule (CLFS) and physician fee schedule (PFS) final rules for calendar year 2019. They include an updated summary of the private-payer rate-based CLFS, a Medicare Learning Network article, and answers to Frequently Asked Questions.

In the 2019 Medicare PFS final rule, the CMS modified the definition of “applicable laboratories” to include hospital laboratories that bill Medicare for nonpatient laboratory services on the CMS 1450 14X type of bill (TOB). Due to the change, hospital outreach laboratories must report their private payer rate and volume data during the 2020 data reporting period (Jan. 1 through March 31, 2020) if they meet each of the following criteria:

  1. They bill Medicare Part B on the CMS 1450 14X TOB.
  2. They receive more than 50 percent of their Medicare fee-for-service (FFS) revenue in a collection period from the CLFS, the PFS or a combination of the two.
  3. They meet a low-expenditure threshold by receiving at least $12,500 in Medicare FFS payments during the period of Jan. 1 through June 30, 2019. 

Effective Jan. 1, 2019, Medicare Advantage plan payments under Medicare Part C are no longer considered “Medicare Revenues” for purposes of determining whether a laboratory received more than 50 percent of its revenues from PFS and CLFS services. This change is expected to increase the number of labs subject to the reporting requirements. 

Members with questions should contact Vickie Kunz at the MHA.

Tags: Medicare, Medicare Advantage, CLFS, hospital outreach laboratories, laboratory services

Posted in: Member News

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