Prior (2018) price reporting cycle offers lessons that can help clinical laboratory benefit administrators and personnel take an informed approach to meeting the requirements of the Protecting Access to Medicare Act of 2014 (PAMA)

With the PAMA Private Payor Price Reporting period under way, some clinical laboratories may be grappling with questions about the new requirements.

Under PAMA, applicable labs must report private payer data on selected Clinical Diagnostic Laboratory Tests (CDLTs) to CMS every three years. For the current cycle, data must be collected from Jan. 1 through June 30.

A six-month review period follows so that laboratories can assess whether the applicable lab thresholds are met. Data must be reported to the Centers for Medicare & Medicaid Services (CMS) during a three-month window starting Jan. 1, 2020, with data due by March 31, 2020.

To help clinical laboratories meet PAMA’s new requirements, CMS defines an applicable laboratory as one that answers yes to the following questions:

1) Does the lab have CLIA certification?

2) Does the lab meet the majority of Medicare threshold, which is either greater than 50 percent of Medicare payments received on CLFS and PFS (Physician Fee Schedule) by National Provider Identifier (NPI) or a hospital lab with a shared NPI bills any Type of Bill (TOB) 14x to Medicare during the six-month reporting timeframe.

3) Does the lab have a minimum of $12,500 payments received from Medicare during the six-month reporting period.

Recent Changes Draw Hospital Outreach Labs

Changes in CMS reporting requirements now include hospital outreach labs, if they meet the other criteria.

Failure to file, or filing late, incomplete, or inaccurate data can result in federal fines for laboratories—up to $10,000 a day.

Sarah Simonson, Director of Laboratory Client Management for Change Healthcare, outlines ways labs can avoid those fines and best prepare for this cycle of private payer reporting.

“Begin with the end in mind,” Simonson said. “Understand what is required and prepare for data extraction.” Simonson is one of several pros who will offer insights during a special post-Executive War College workshop geared to private payer price data reporting under PAMA.

Labs should allow ample time to review extracted data, Simonson said, as well as evaluate the data for quality assurance. It’s also important to understand login requirements and the format required to deliver the data. That means getting your IT team involved.


Trish Hankila, Chief Financial Officer of South Bend Medical Foundation, will return to the Executive War College on Lab and Pathology Management, for a special post-conference workshop on the PAMA price reporting requirement. (Photo copyright: Dark Daily)

Having learned many lessons from the previous reporting cycle, Trish Hankila, Chief Financial Officer of the South Bend Medical Foundation, recommends talking with your internal IT or vendor to ensure that accounts receivable (A/R) reports capture the required data. Review available data to ensure accuracy and completeness of data, and review the A/R report that will be used to transmit that data, she says. 

Hankila, who will also speak at the 24th Annual Executive War College post-conference workshop encourages a visit to the CMS website to obtain documents regarding the data, registration, and submission requirements.

“The Center for Medicare Management, CLFS User Manual explains in detail how to log in to the CMS portal, register the data submitter and data certifier, and the process for submitting and certifying the data,” Hankila said.

CMS will use the data collected to calculate 2021 fees for each individual laboratory Current Procedural Terminology (CPT) code.

“CMS is trying to establish fees that reflect the market value of the tests being performed, using a weighted average of the various amounts paid per CPT code by third-party payers,” Hankila said.

How to structure your data when working with your internal IT team or third-party billing will be one focus of the PAMA workshop, in addition to how to avoid the pitfalls when gathering, analyzing, and reporting lab test price data. The post-conference workshop will benefit administrators and personnel responsible for reporting PAMA data.

“What Hospital and Health Network Labs Must Know to Comply with PAMA Private Payer Price Reporting,” will take place from 8 a.m. to 5 p.m., May 2, in New Orleans.

“The takeaways include understanding PAMA, lessons learned from the prior (2018) cycle, and how to structure your request to your IT/billing department,” Simonson said.

To help attendees prepare to participate in the PAMA workshop, Hankila previewed what South Bend Medical Foundation has learned:

  • Get started early with data gathering and the reconciliation process;
  • Reconcile the data by using other reports from your A/R system;
  • Ensure you have enough time to modify programs; and
  • Do not wait until the last minute to transmit the data.

“There may be issues with registration of the submitter and certifier in the CMS portal, the CMS website, or with your data file that you have prepared for submission,” Hankila said.

More Upcoming PAMA Workshop Highlights

Elizabeth Sullivan, JD, will cover “Compliance and Regulatory Issues Associated with the PAMA Statute and the CMS Final Rule for Reporting Private Payer Lab Test Prices: Risks, Consequences, and Often-Overlooked Requirements.”

Diana Voorhees, MA, CLS, MT, SH, CLCP, CPCO, will cover “Understanding the Requirements for Reporting PAMA Private Payer Lab Test Price Data: Who Reports, What Is Reported, How to Report, When Penalties Apply, and More.”

Kyle C. Fetter, MBA, BA, will present “Key Recommendations for Reporting Your Lab’s Private Payer Price Data: Identifying Data Sources, Using Informatics Tools, Understanding Where Data is Missing or Inaccurate, and Transmitting Your Data.”

Visit executivewarcollege.com for more information and to register.

—Tammy Leytham

Related Information

Useful Lessons for Labs That Report PAMA Data

CMS PAMA Regulations Home Page

Registration for Executive War College Post-Conference Workshop