PAMA Solutions

PAMA Reporting for Labs

The Protecting Access to Medicare Act of 2014 (PAMA) revised the payment methodology for clinical diagnostic laboratory tests paid under the Medicare Clinical Laboratory Fee Schedule (CLFS). Under PAMA, CMS will base 2023 clinical laboratory fee schedule payment rates on private payer rates as reported by applicable labs.

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CMS Delays PAMA

In January 2020, CMS delayed the PAMA data reporting period from 2020 to 2021. Applicable laboratories were given an additional year to report final payment data collected during the first six months of 2019. In March 2020, the Coronavirus Aid, Relief, and Economic Security (CARES) Act was signed into law. The CARES Act included two provisions that impacted the PAMA program. First, it provided an additional one-year delay from reporting requirements under PAMA; second, it delayed cuts to the clinical laboratory fee schedule by one year. The specifics related to these provisions are pending final publication by CMS.

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In November of 2018, CMS released its 2019 Physician Fee Schedule Final Rule, which contained new data collection criteria that will likely increase the number of applicable labs. These new criteria include the following changes to the applicable lab determination:

  • Medicare Advantage (Part C) payments are now excluded from the total Medicare revenue calculation used to determine whether a laboratory receives a majority of Medicare revenue under CLFS and/or MPFS (Medicare Physician Fee Schedule).

  • Hospital outreach laboratories that bill non-patients for their laboratory services (and meet the other criteria) are now considered applicable labs.

  • Quadax has updated our systems to incorporate these new criteria and is providing our clients tools to assist them in making the decision on whether they are an applicable lab subject to reporting. For applicable labs, we will obtain the final payment data from our systems and supply that data to our clients.