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.
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.
R. Sharma, is a seasoned healthcare professional with over 20 years of clinical and operational experience. As a registered nurse and midwife, his deep clinical foundation spans hands-on patient care, health information management, revenue cycle management, and health technology systems.