YOUR PRACTICE'S MEDICARE LAB RATES FOR THE NEXT THREE YEARS ARE BEING SET RIGHT NOW.
For six years, Medicare's clinical laboratory rates have been shielded from PAMA's scheduled reductions. That protection expires. In each of 2027, 2028 and 2029, payment for a test can be reduced by up to 15% against the prior year's amount.
Those rates are being built from private-payor data that certain laboratories — including physician office laboratories — were required to report between May 1 and July 31 of this year. CMS has already begun publishing the list of test codes for which it received no data at all. Where nothing was reported, CMS sets the price by crosswalking or gapfilling instead.
Here is what most practices missed. That obligation never depended on hearing from CMS. It applied to every applicable laboratory by regulation. CMS did mail notices to practices it thought might qualify, but the agency has been explicit that it cannot verify status from its own data. A letter was not a determination. And no letter was not an exemption.
So every practice with in-office testing now faces the same retrospective question: were we an applicable laboratory between January and June 2025 — and can we show our work?
Most practices never ran the analysis. Fewer ran it correctly. A CLIA Certificate of Waiver still counts. Billing on a CMS-1500 changes nothing. And a shared NPI can pull your entire practice's Medicare revenue into a calculation you never knew you were part of.
The window closed July 31. CMS has announced no extension and no late-filing process. The next reporting cycle is 2029 — so whatever conclusion your practice reached this summer is the one you will be living with, and defending, for three years.
Webinar Objectives
This session will explain how the Protecting Access to Medicare Act reshaped the Medicare Clinical Laboratory Fee Schedule and why physician office laboratories sit squarely inside that framework. We will walk through the four-part applicable laboratory test as CMS applies it to a physician practice, work through both revenue threshold calculations using the January through June 2025 data collection period, untangle the National Provider Identifier scenarios that determine whether a practice qualifies, review what applicable information had to be reported and what had to be excluded, address documentation expectations for practices that concluded they were not applicable, examine submitter and certifier responsibilities, discuss civil monetary penalty exposure and appropriate remediation, and map how reported and unreported data will shape Clinical Laboratory Fee Schedule payment rates for 2027 through 2029.
Webinar Agenda
- Understand the PAMA reporting framework and why it applies to physician office laboratories
- Recall the four-part applicable laboratory test and the January through June 2025 data collection period
- Understand the majority of Medicare revenues threshold calculation
- Recall the $12,500 low expenditure threshold and how it is measured
- Recognize how NPI assignment and billing determine applicable laboratory status
- Identify the practice structures under which a physician office laboratory cannot qualify
- Understand what constituted reportable applicable information
- Recognize documentation expectations for a non-applicable determination
- Understand submitter and certifier roles and separation of duties
- Recall civil monetary penalty exposure and appropriate remediation steps
- Understand the Clinical Laboratory Fee Schedule rate-setting timeline for 2027 through 2029
Webinar Highlights
- Identify whether your practice met the applicable laboratory definition during the data collection period
- Discuss why CLIA Certificate of Waiver status does not exempt a physician office laboratory
- Identify which Medicare revenues belong in the numerator and denominator of the threshold calculation
- Discuss the treatment of Medicare Advantage payments in threshold calculations and in reporting
- Recognize the shared NPI scenario and its effect on group practices
- Identify the documentation to retain in support of a non-applicable conclusion
- Discuss reportable versus excluded applicable information
- Recognize appropriate next steps if a required submission was not made
- Identify the CMS milestones and published code lists that will determine 2027 payment rates
- Discuss practical steps to prepare for the next reporting cycle
Who Should Attend
- Medical billers and billing specialists
- Medical coders and coding specialists
- Charge entry, claims and claim edit staff
- Revenue cycle managers and directors
- Practice administrators and practice managers
- Credentialing and provider enrollment staff
- Compliance officers, compliance managers and compliance analysts
- Practice CFOs, controllers and finance directors
- In-office laboratory managers and supervisors
- Laboratory medical directors and technical consultants
- Physicians and practice owners with in-office testing
- Group practice, IPA and MSO leadership
- Healthcare attorneys and regulatory consultants
- Billing companies, RCM vendors and outsourced coding firms
- Auditors and internal review staff
What Do You Think About This Webinar?
