Important Notice for Medi-Cal Clinical Laboratory Service Providers
We have informed you of the effort by DHCS to establish a reporting process for Medi-Cal clinical lab providers to indicate their reimbursement/payment rates by other non-Medi-Cal/Medicare payers. The CSP has been working in the stakeholder process to refine how this information would be submitted and what types of payments would be impacted. We think there has been some real progress in those areas, but the data submission requirement obviously remains and all pathology groups that have independent labs or bill globally to Medi-Cal need to collect and report this reimbursement data by May 31, 2013. It can be submitted electronically and we have included below the notice from DHCS and links to the summary and electronic documents. You need to submit reimbursement information from 2011.
This is a copy of the DHCS notice and summary on this submission requirement:
Assembly Bill 1494 (Chapter 28, Statutes of 2012) authorizes the Department of Health Care Services (DHCS) to develop a new rate methodology for clinical laboratory and laboratory services (CLLS). The new rate methodology determines rates that are comparable to payment amounts received by other payers. To establish this methodology, AB 1494 directs CLLS providers that billed Medi-Cal in 2011 to submit data reports based on the 2011 calendar year.
DHCS must determine the average lowest price providers receive from third-party payers other than Medi-Cal and develop rates for these services at either the lowest rate other payers are paying or at 80 percent of the Medicare rate, whichever is lower. DHCS held several stakeholder meetings between August 2012 and March 2013 to finalize the data elements to be collected and the format to be used for data submission.
DHCS has posted the final rate methodology proposal and electronic spreadsheet that providers must use to electronically submit fee schedules to DHCS on the Clinical Laboratory and Laboratory Services Rate Methodology Change page of the DHCS website. Providers must email their completed fee schedules spreadsheet to email@example.com. All data submissions must be submitted to DHCS electronically.
To ensure providers have adequate time to prepare and submit the data, the deadline for the submission has been extended to May 31, 2013. The data reports submitted to DHCS must be certified by the provider's certified financial officer or an authorized individual. Providers' data submissions are confidential.
For more information, providers may email DHCS at firstname.lastname@example.org or visit the Clinical Laboratory and Laboratory Services Rate Methodology Change page of the DHCS website.
Some important points on changes that CSP requested and was granted:
(1) Requires labs that had either total Medi-Cal paid claims amount of $100,000 or more or total claims paid 5,000 or greater to submit their payments for 2011 from other private payers. There is a list of NPI numbers that have been determined to be required to submit this data. If you have multiple NPI numbers for different locations you can submit only one data report.
(2) You are only required to submit global payments so no split billed charges. No reporting for hospital services unless there is an outreach lab that operates in the hospital and provides services to non-hospital patients.
(3) You submit payment data only from your top 5 fee for service with the largest volumes. If the top 5 don't account for 80% of your aggregate Fee for Service payments then submit for others until you reach that percentage, in no case more than 10 payers. If a payer , like Blue Shield, has multiple types of plans/programs within its portfolio you can count each of the different ones as one of the 5. You don't need to ID the payer but should maintain that information in your records if it needs to be confirmed. You don't submit Medi-Cal or Medicare payments as part of your FFS payments.
Here is a link to the summary and the data submission electronic format document. Remember it is payment data from 2011 and you need to report by May 31, 2013. If you have any questions please contact the CSP office.