The Centers for Medicare & Medicaid Services (CMS) will launch the system that applicable laboratories will use to submit private payer data for clinical laboratory tests to the Medicare program on November 14. Certain laboratories are required to report private payer rates, codes, and volumes for clinical laboratory tests under the Protecting Access to Medicare Act (PAMA) starting in 2017.

The Medicare agency reviewed the system's launch, laboratory registration, and data reporting methods during a November 2 national provider call . The CMS' PAMA presentation slides are available for download. The CAP will continue to engage with the CMS on the implementation of PAMA and update its members on program requirements and deadlines.

Laboratories subject to the reporting requirement under PAMA must collect private payer rates for clinical laboratory fee schedule (CLFS) services for the first data collection period beginning January 1, 2016, through June 30, 2016. These laboratories then must report their private payer data to the CMS beginning January 1, 2017, through March 31, 2017. The CMS will use this data to calculate CLFS payment rates based on the weighted median of private payer payments for 2018.

New details about the PAMA reporting system from the national provider call and materials include:

  • Submitters must access the CMS enterprise portal to register and access the CLFS data collection system to initiate reporting.
  • Users must register for a specific role, submitter or certifier of data. These must be two different individuals. The certifier cannot make adjustments to data, but must work with the submitter to do so before certifying the data. Data collected by laboratories can be populated by manual entry or file upload.

Download the list of CLFS codes subject to collection and reporting requirements.

If users need assistance in using the reporting system, the CMS has established a specific help desk that can be reached at or 855-876-0765.

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On November 8, the CAP will host the webinar "The Final 2017 Medicare Physician Fee Schedule's Impact on Pathology Services." This presentation is for CAP members and starts at 2 PM ET/1 PM CT.

Throughout this hour-long panel discussion, CAP experts will explain the changes by the CMS in the 2017 Medicare Physician Fee Schedule. Our featured presenters are Patrick Godbey, MD, FCAP; Jonathan Myles, MD, FCAP; Mark Synovec, MD, FCAP; and John Scott, VP of CAP Policy and Advocacy.

Those unable to attend the webinar live should still register in order to receive a link to an archive recording of the presentation later this week.

During the webinar, CAP experts will discuss how the final rule affects Medicare reimbursement for pathology services and the CAP’s advocacy efforts to impact these changes. The second part of the webinar will be a question-and-answer session.

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On November 2, the CAP hosted a 60-minute webinar to discuss 2017 options for preventing Medicare penalties and, in certain cases, increase reimbursements in 2019. A recording of the webinar is available to view at your convenience.

Watch the webinar recording and download the presentation slides.

On October 14, the CMS issued its final rulemaking that implemented provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Measurement for new quality payment programs will begin in 2017 and affect Medicare reimbursement in 2019. One payment pathway, the Merit-based Incentive Payment System (MIPS), is projected to have a $1.5 billion impact on pathology reimbursement between 2019 and 2024.

The CAP webinar was led by Patrick Godbey, MD, FCAP; Diana Cardona, MD, FCAP; and Stephen Black-Schaffer, MD, FCAP.

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Advocating to ensure health plans maintain adequate networks of providers, the CAP joined with the American College of Radiology and the American Society of Anesthesiologists to call on Idaho state insurance officials to take a different approach to dealing with network adequacy and out-of-network balance billing.

In October 27 comments on draft legislation related to network adequacy, the groups—part of the Coalition of Hospital-Based Physicians—said that legislation proposed by the Idaho Department of Insurance incorrectly focuses on out-of-network balance billing rather than ensuring that health plans maintain adequate networks of hospital-based physician providers at in-network facilities.

"Accordingly, the Department should ensure that any plan offered to the public is evaluated to ensure that enrollees have access to in-network physician specialists at in-network hospitals and facilities," the groups say in their comments. This includes determining whether the network includes anesthesiology, pathology, radiology and hospitalist services in sufficient numbers at any in-network facility or in-network hospital included in such plan so that patients enrolled in these plans have reasonable and timely access to these services in-network.

The CAP has long been a proponent of network adequacy and along with the American Medical Association has urged the Department of Health and Human Services to establish policies that will help ensure network adequacy as a way of reducing unanticipated bills from providers.

Flawed Payment Methodology

In their comments, the groups said they strongly oppose the out-of-network payment methodology set forth in the draft legislation, noting that the problem of balance billing emerges in scenarios where patients cannot access in network provides at in-network hospitals and facilities. As proposed, the legislation would deny out-of-network Idaho physicians the legal authority to negotiate appropriate payment with the health insurance plan for medical services that were rendered to their enrollees.

"As noted, the out-of-network care is frequently the result of the health plan's failure to contract for such services that would otherwise be available to the patient," the groups stated.

Under the proposed legislation, the health insurance plan payment schedule (the carrier's contracted rate), as the lesser value, would become the de facto payment methodology that all physicians would be compelled to accept under Idaho law. "Any codification of such methodology is an extraordinary intervention by the Idaho government to tilt the economic equilibrium of payment negotiations, on the value of physician services, inexorably in favor of health insurance plans," they write. "The likely consequence of such an action could be a dramatic dismantling of physician networks by both parties (health plans and providers), who will have no economic incentive to negotiate contracts given that the health plan is granted unilateral payment control."

The Coalition supports the use of usual, customary and reasonable rates tied to the market value of physician services based on the use of an independent charge database (ie, FAIR Health Inc.). Such a methodology is now in use in multiple states.

Finally, the Coalition believes the legislation should ensure that patients' out-of-pocket payments to non-participating providers are properly attributed to the patient's in-network deductible, or if that is already met, to the maximum out-of-pocket allowance. It also opposes efforts to deny physician economic discretion to waive co-insurance, co-payments or deductibles.

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