Wednesday, July 17, 2019

Very Brief Blog: This Year's Proposed Gapfill Pricing: How Late Is It?

Each year, CMS has the option of pricing new lab codes through the crosswalk process of the gapfill process.  In the gapfill process, CMS determines in the fall these new codes don't have a good crosswalk pricing solution, and gives them to its MAC contractors to price in the following calendar year. 

MAC proposed prices are supposed to come out by late spring, receive public comment, and then final gapfill prices can be revised by the MACs for publication in the fall.

This year, the proposed gapfill prices are later than ever.  Here are some dates.

2015:  29 gapfill codes, proposed May 26, final September 25.

2016:  15 gapfill codes, proposed June 10, final September 30.

2017:  (No gapfill codes??)

2018:  15 gapfill codes, proposed June 13, final October 19.

2019:  18 codes under gapfill (list here).  No proposed pricing released as of ...July 17, 2019.

This year's gapfill pricing is over one month late, relative to recent benchmarks.
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Links to blogs on various past years' gapfill processes, here.

CMS's own rules require MACs to submit contractor-specific amounts "on or before March 31," and since the only explicit thing CMS must do is calculate medians, the delay is perplexing (see 81 FR 41084.)  MACs are supposed to submit revised amounts by September 1, but they can't do that if the comment period overrides September 1 due to late release of proposed prices.

CMS states in regulation it will post gapfill proposals by April 30 (42 CFR 414.509) and take public comments for 60 days.   Thus, public comments will run this year til at least late September of 2019.

CMS must provide an explanation of "rationale" for crosswalk decisions under statute (p. 41086), and promised to provide an explanation of gapfilled amounts after January 1, 2017 (p. 41086, bottom middle column and 42 CFR 414.506(d)(4).  )


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