In fact, the HHS Office of Inspector General has estimated that only 5% of all clinical laboratories will submit all of the data used by CMS to compute the new CLFS
CMS regulations specify 2 ways to price new CLFS
tests, "crosswalking" and "gapfilling" (10).
These totals include all HCPCS test codes listed in the CLFS
, and therefore include waived tests and venipuncture.
The final PAMA rule, issued by CMS in June 2016, delayed the CLFS
overhaul by one year and expanded the sphere of labs from which data will be collected to include hospital outreach testing programs, but only if the outreach lab has its own National Provider Identifier (NPI).
Discuss two reasons for the actual decreases in reimbursement for laboratories since the CLFS
CMS expects to publish the recalculated prices under the CLFS
in early September 2017.
As new tests are developed and added to the CLFS
each year, the corresponding payment amounts may be set based on
These fees will be applied to all who are paid on the CLFS
and will likely extend to private payors who pay using a function of the CLFS
Section 216 of PAMA requires CMS to re-price each test on the CLFS
based on market pricing data gathered from "applicable laboratories.
Beginning in January 2018, Medicare's payment rates (under the CLFS
) will use private payer rates to set CLFS
rates, which are projected to be 20 percent to 30 percent less than the current CLFS
Section 216 of PAMA describes an applicable lab as one that derives at least 50% of its Medicare revenues from payments under the CLFS
or the physician fee schedule, and has at least $50,000 in annual revenues from the CLFS
To truly impact utilization, one needs to address prescriber behavior, since all CLFS
services must be ordered by a licensed clinician.