Collecting and Reporting Private Payor Data to Meet PAMA Requirements (Infographic)
Collecting and Reporting Private Payor Data to Meet PAMA Requirements (Text Version)
Determine whether your laboratory is a Protecting Access to Medicare Act (PAMA) “applicable” laboratory. If so, your laboratory must report private payor data for clinical diagnostic laboratory tests to the Centers for Medicare and Medicaid Services (CMS) in 2017.
PAMA Core Requirements
| Applicable Laboratory | Medicare Revenues | Private Payors | Penalties |
|---|---|---|---|
| “>An applicable laboratory must have CLIA certification (including a certificate of waiver). Further, the CLIA-certified laboratory’s own billing National Provider Identifier (NPI) is used as the mechanism for determining an applicable laboratory. | Medicare revenues are based on the final paid claims received by the laboratory’s billing NPI from the physician fee schedule (PFS) and clinical laboratory fee schedule (CLFS) during the collection period. | Private payors consist of health insurance issuers, group health plans, Medicaid managed care, and Medicare Advantage plans. | By law, Medicare can levy penalties of up to $10,000 per day for each failure to report, misrepresentation of data, or omission in reporting. |
Laboratory Reporting Logic
- Reporting Required
- More than 50% of its total Medicare revenue comes from CLFS and PFS.
- Received more than $12,500 in Medicare revenue for CLFS services from January 1–June 30, 2016:
- Applicable laboratory must collect, certify, and report private payor data.
- Received $12,500 or less in Medicare revenue for CLFS services from January 1–June 30, 2016:
- Laboratory does not collect and report private payor data. (STOP)
- Received more than $12,500 in Medicare revenue for CLFS services from January 1–June 30, 2016:
- More than 50% of its total Medicare revenue comes from CLFS and PFS.
- Reporting Not Required
- Less than 50% of total Medicare revenue comes from CLFS and PFS.
- Laboratory does not collect and report private payor data. (STOP)
- Less than 50% of total Medicare revenue comes from CLFS and PFS.
| 2016 | 2017 | 2018 |
|---|---|---|
| 1/1/2016–6/30/2016 Collection period |
1/1/2017–3/31/2017 Reporting period |
1/1/2018–12/31/2018 New CLFS rates |