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PAMA 2019 - Compliance Update

Today’s medical laboratories wrestle with reduced reimbursement 1. Expansion of “applicable reporting labs” brings additional data
rates under PAMA’s revised CLFS final rule. The restructuring is from Independent and Outreach Hospital Labs.
having a hefty impact and is forcing laboratories to reorganize in 2. With the new calculation methodology CMS suggests that 43%
order to survive the new changes. The new rules for what more labs may be included as “applicable labs”.
constitutes an “applicable lab” and the new reporting 3. Hospital labs will be identified by CMS as an “applicable lab”
Two major trends have emerged on the forefront, one is the requirements that started January 1, 2019, are adding another using Form CMS-1450 14x bill type vs NPI.
consolidation of traditional laboratory testing and second one is level of complexity to reporting and compliance concerns.

point-of-care testing The timeline for the second round of data is as follows:
As healthcare reform continues to struggle with how healthcare is • Laboratories will collect private payor “payment” data
both delivered and billed across the country, Genome Web, from January 1 to June 30 2019.
A new wave of patients are educating themselves and are Genomics: There will be extensive use of DNA a genetics, genomics and molecular diagnostic online news • Data is to be reported to CMS by March 31, 2020.
becoming more proactive in their healthcare. Many probes, neonatal genetic screening, viral load monitoring, states in 2017 CMS expects PAMA to save the government $3.93 • Medicare CLFS rates (based on weighted median
believe this will decrease laboratory volume and drive high-density SNP diagnostic assays, electrochemical billion by 2028. private payor rates) in November 2020 and be effective
down the cost of laboratory testing due to home kit detection of infectious agents, gene mutation analysis,
testing. Genome testing is on course to continue to give a and protein profiling. January 1, 2021.
greater insight into linking DNA sequences and disease. RCM Enterprise Services recognizes the changes in laws,
These predictions are geared towards eradicating Proteomics: Proteomics is believed to be a source regulations and government requirements. With new changes in As financial integrity is critical, each organization should insure
diseases through better treatment, allowing humans to for future diagnostic testing. It is expected the
live longer, healthier lives. development of analytical systems will have the laboratory billing/reimbursements happening at a fast pace RCM that the data is analyzed, audited, validated and signed off by
capacity to test hundreds and thousands of different will provide updated information in the RCM quarterly magazine. multiple stakeholders.
Point-of-Care Testing: Many experts strongly proteins. Many proteins remain unstudied and could form
believe the future of laboratory medicine will be inclined the beginning of a new way of testing.
towards more testing at point-of-care. This type of testing PAMA Update 2019 Reminder of data collection details:
offers several benefits, including lower costs, portability, Taking a futuristic view into new market trends will more After two years of 10% CLFS reimbursement rate cuts annually • Included: Private Payor designation: Commercial, contracted
simplicity, flexibility, and built-in quality control. than likely lead to new technological discoveries and and industry lawsuits and appeals, which led to the expansion of and non-contracted, Group health plans; Medicare Advantage
account for an economic uptick in laboratory medicine. laboratories qualifying as applicable labs, it is now time to begin and Medicaid managed care plans.
Automation and Robotics: This is one of the Making these changes will steer laboratory testing to
most popular predictions. The use of transport models to reach new heights in the quality of healthcare worldwide. the second round of PAMA data collection. With the updates and • Do Not Include: Medicaid fee-for-service, Other government
deliver specimens and humanoid technology seems to changes, laboratories of all sizes and structure need to review payors
be a fascinating concept in laboratory medicine but yet to and understand the applicable Lab Definitions to insure • Only “Fully Adjudicated” claims within the reporting period
become a reality.
compliance. (not forgetting recoupments, adjustments and redeterminations)
(https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Pay- For additional reading click www.nila-usa.org
ment/ClinicalLabFeeSched/PAMA-Regulations.html) National Independent Laboratory Association.
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