Clinical Laboratory Services Rate Methodology
January 2019 Update:
2019 Clinical Laboratory or Laboratory Services Data Collection
As the first step in developing the July 1, 2020 lab reimbursement rates, certain providers are required to submit third-party payer rate and utilization data for calendar year 2018. Data submissions must be submitted to the Department of Health Care Services (DHCS) by June 30, 2019. The lists provided below identify the procedure codes subject to reporting and the providers by National Provider Identifier (NPI) number that are required to submit data:
Please see DHCS Form 6015 below for instructions and submission form:
Please submit completed submission forms, questions, or comments, to the DHCS Clinical Laboratory mailbox: email@example.com
In accordance with Assembly Bill (AB) 1494 (Committee on Budget), the DHCS is required to:
Implement a ten percent payment reduction, excluding services under the Family Planning, Access, Care and Treatment (FPACT) program and outpatient hospital services, effective July 1, 2012 through June 30, 2015, for clinical laboratory and laboratory services until a new rate setting methodology is approved by the Centers for Medicaid & Medicare Services (CMS).
As required by statute, the AB 97 payment reduction is also applied to the new payment methodology.
Data Collection Process
DHCS underwent a significant stakeholder process to develop the data collection tool to be used for the development of the new methodology and to determine the new rates under that methodology.
Beginning in 2012, DHCS conducted meetings with clinical laboratory stakeholders to develop a data collection methodology that was operationally feasible and consistent with the intent of the legislation.
DHCS requested third-party payer rate and utilization data from providers and limited the use of data to codes that met either of the following two thresholds based on the prior year's Medi-Cal paid claims data:
Medi-Cal paid claims volume equal to or greater than 1,000
Total Medi-Cal paid amount equal to or greater than $500,000
The thresholds for choosing providers required to submit utilization data are:
Medi-Cal paid claims volume equal to or greater than 5,000
Total Medi-Cal paid amount equal to or greater than $100,000
New Rate Methodology
DHCS utilizes the data collected to develop the new rate methodology. The following represents the steps taken in the determination of the average of the lowest rate.
DHCS uses the range of rates that fall between zero and eighty percent of the calculated California specific Medicare rate. (Note: Medi-Cal does not have the authority to reimburse above eighty percent of the Medicare rate. Rates exceeding this threshold were excluded.)
These rates are then weighted based on the units billed to create an average.
The methodology is individually applied to each code meeting threshold requirements, excluding codes for which no third-party rate and/or utilization data was submitted, or if the services under that code were terminated or no longer a Medi-Cal benefit.
To ensure that requirements of the provisions of statute continue to be met, DHCS will collect third-party payer rate and utilization data every three years, beginning in 2019, from clinical laboratory or laboratory services providers. Rates are required to be calculated based on the prior year’s data and application of the new methodology will be limited to those codes meeting either of the two thresholds. DHCS will continue to monitor the thresholds and methodology and make changes as necessary to comply with the law, access requirements, and account for other operational or programmatic issues.