Labs Begin Sending Payment Data to Medicare for New Pricing 

The next big step in Medicare moving to a market-based reimbursement model begins this month for many clinical laboratories. Under the Protecting Access to Medicare Act (PAMA), laboratories, including physician office laboratories, must report before March 31 private payer rate and volume data based on a previous 6-month period, January 1, 2017 to June 30, 2016. Laboratories must provide the final payment made for each test, the Healthcare Common Procedure Coding System code associated with the test, and the volume of tests for each payer. After analyzing this data, the Centers for Medicare and Medicaid Services (CMS) will post new clinical laboratory fee schedule (CLFS) rates based on the weighted median of private payer rates in November 2017, which become effective January 1, 2018.

Not all labs must report data—only applicable laboratories under PAMA. Applicable laboratories are those that receive more than $12,500 in Medicare revenues from laboratory services on the CLFS and more than 50% of their Medicare revenues from laboratory and physician services during a data collection period, among other requirements. CMS held a conference call on November 2, 2016 about how to report data and posted the data submission details shared during the call on, under national provider calls and events. 

As Millions Enroll in Exchanges, Ryan Plan Hints at Affordable Care Act Replacement 

Republicans and President-Elect Trump have made repealing and replacing the Affordable Care Act (ACA) a high priority, yet 1 week after the election, officials at the Department of Health and Human Services (HHS) said they were “all in” for the 2017 open enrollment on In the first 2 weeks, more than 1 million consumers logged in and selected plans, including 246,433 new enrollees. Open enrollment continues through January 31. Because insurers have already negotiated payment with healthcare providers and received approval from HHS, their contracts with consumers for 2017 are likely to remain in force.

In October 2016, HHS announced that premiums for marketplace plans would rise 25% on average, a number widely reported in the news media. However, HHS analysis shows that 77% of returning marketplace consumers will be able to find a plan for no more than $100 per month and 72% will be able to find a plan for $75 per month or less, similar to metrics for previous years. Tax credits will adjust to match changes in premium costs. Moreover, the HHS analysis found that if all consumers switched to the lowest-cost available premium plan, the average 2017 marketplace premium after tax credits would decrease 20%.

The most detailed replacement plan Republicans have put forward retains some of the benefits, and policy tools, that underlie the Affordable Care Act. Part of House Speaker Paul Ryan’s Better Way package of policy proposals, the plan would offer tax credits to consumers without access to employer-sponsored plans to help them buy private insurance. Tax-advantaged healthcare savings accounts would play a prominent role, encouraging greater use of high-deductible plans. Ryan would also limit tax deductions for employer-sponsored insurance, another possible driver of high-deductible plans. Other proposals include allowing small businesses and individuals to pool resources and negotiate for insurance as groups, encouraging employer wellness plans, reforming medical liability laws, creating tax-subsidized high-risk pools, and guaranteeing coverage for pre-existing conditions for those who maintain continuous coverage. Details of Ryan’s plan are available at