The Centers for Medicare & Medicaid Services (CMS) has released a final rule requiring laboratories performing clinical diagnostic laboratory tests to report the amounts paid by private insurers for laboratory tests. Medicare will then use these private insurer rates to calculate Medicare payment rates for laboratory tests paid under the Clinical Laboratory Fee Schedule (CLFS) beginning January 1, 2018.

CMS moved implementation of the new lab billing payment system from January 1, 2017, to January 1, 2018, to allow laboratories sufficient time to develop the information systems necessary to collect, review and verify data before reporting applicable information to CMS.

Medicare presently pays for clinical diagnostic laboratory tests (CDLTs) under the CLFS. The CLFS provides payment for approximately 1,300 CDLTs, and Medicare pays approximately $7 billion per year for these tests.

The CLFS was first adopted in 1984, and CLFS rates have only been updated since that time to establish payment for new tests or to make statutory, across-the-board updates.

Under the final rule, CMS is adopting the following schedule implementation of the new payment:

  • First data collection period for determining calendar year (CY) 2018 CLFS payment rates: January 1, 2016, through June 30, 2016.
  • First data reporting period for reporting entities to report private payor rate data to CMS for determining CY 2018 CLFS payment rates: January 1, 2017, through March 31, 2017.
  • Annual laboratory public meeting for new tests: mid-July 2017. CMS will use crosswalking or gapfilling to set rates for new tests (that are not new ADLTs) for which there is no private payor data collected for CY 2018.
  • CMS publishes preliminary CLFS rates for CY 2018: early September 2017. The public will have approximately 30 days, through early October 2017, to submit comments on the preliminary CY 2018 rates.
  • CMS makes final CY 2018 CLFS rates available on the CMS website: early November 2017.
  • Implementation date of new CLFS: January 1, 2018.

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