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Keeping an Eye on CMS Payment Rate Updates

Each year, the Centers for Medicare & Medicaid Services (CMS) releases four fee schedules needed for service pricing: physician, drugs, durable medical equipment (DME) and clinical lab. The timing of their release can affect year-end activities Medicaid program managers must undertake to make sure their MMIS is ready to process and pay claims accurately for the next year.

In 2017, CMS changed how the clinical lab payment rates were calculated, causing a lack of clarity about the release of the actual fee schedule and resulting in a delay. The interchanging of terms – rates and fee schedule – caused confusion. In looking at the payment rates information released November 21, it seemed possible that these were the fees for established codes; but there were no fees for the new 2018 codes – only the formulas for establishing them using existing codes to be cross-walked. The fee schedule was released December 15, just a couple of weeks before implementation on January 1.

By examining this situation (and a few other oddities surrounding the clinical lab fee schedule), Medicaid programs can learn what steps to take to reduce confusion around service pricing. You can learn more here.