Wednesday, March 13, 2019

CMS Tries to Make PAMA Simple: New Educational Materials 1Q2019

CMS has posted several new educational documents to help labs understand whether they will need to report 1H2019 private payer payments, when the reporting period opens in 1Q2020.

See the somewhat cluttered PAMA page at CMS here.  (Enter at your own risk).

See some specific materials from a January 22, 2019 town hall call here.  (Includes deck and a full transcript, and an audio file you can download to replay over and over).

  • See a summary of the rules updated as of February 27, 2019: here.
  • See a 25-page revised information set, also revised February 27, 2019:  here.
  • Finally, completing the February 27, 2019, trifecta, see a 14 page Q&A on PAMA, here.

I am not a card-carrying PAMA expert, but it looks to me like we are switching from essentially no hospital labs reporting in 2017, to large numbers of hospital labs reporting in 2020. 

Why?  In 2017, a hospital lab had to bill Medicare under its own NPI to be a reporting entity.  This was very rare.

Next year, hospital labs have pretty simple standards for becoming a reporting lab.  They have to bill Medicare (at least $1) on a 1450 outpatient form for a Medicare non-patient (meaning the hospital lab is providing tests for other than registered inpatients and outpatients).   Then, based on 1450 forms, the lab has to get more than 50% of its revenues from Medicare Part B (PFS/CLFS).   This either goes to one extreme or the other.  If you view the NPI as the collecting entity, then the hospital NPI probably gets more revenue from the Outpatient APC system on 1450 forms, than it gets from B (CLFS/PFS).   However, if you view the lab as the collecting entity, or you look only at 1450 collections for "non patients," 100% of its revenue will be from CLFS/PFS on its 1450 forms since there is no APC revenue for "non patients."   CMS itself notes that the latter will be the case (page 7 of the Summary document).  Also, CMS notes that it is not all 1450 forms, but 14X 1450 claims (nonpatients) and not 13X 1450 claims (outpatients).

Finally, the entity must get at least $12,500 from the CLFS in the six-month collection window, or about 1,000 $12 lab tests.

Once a hospital lab is reporting, it reports lab test prices for its (non-Medicare) non-patients, see Q&A, Q3.22, Q3.23, Q3.24.   However (!) if the lab does bill on its own NPI (which is rare), and it acquisitions labs from both outpatients and non patients, then it reports both (Q.25).

An interesting note is that hospitals should combine outreach laboratories for calculations, if it has more than one (Q3.8).  For example, if it had two outreach labs that both bill Medicare for $8,000, together they met the $12,500 line.

Not specific to hospitals, CMS confirms that if a lab test is initially paid during the data period (say, $20) and is appealed and paid more after the reporting period (say, $40), then that claim is not reported at all, since the final payment is not within the reporting period.  CMS also reconfirms that unlisted code payments are not reportable.