"MoPath Pricing Update"

Palmetto: ‘We Are Processing & Paying Clean Claims without Undue Delay’

Medicare contractor says it established gap-fill pricing on January 31 and any delay to labs ‘was minimal’

SEEING THAT PALMETTO, GBA, the nation’s largest Medicare Administration Contractor, seems to be at the center of the controversy over how Medicare is to pay for molecular pathology (MoPath) tests, THE DARK REPORT sent a list of questions to Palmetto Vice President Mike Barlow. Here are the questions and his answers.

Q: Is it true that Palmetto has not paid any labs for molecular tests on invoices submitted this year?

A: As of January 31, we established the gap-fill pricing for the majority of MoPath codes and have been processing claims. As these new codes and their pricing were effective for DOS 1/1/2013 and later, the delay to the labs was minimal. Some Tier II codes affecting a smaller sub-set of claims were manually priced until the gap-fill analysis was completed.

Q: If no payments have been made, what is the reason for the delay?

A: This isn’t applicable to us, but all Medicare contractors had to establish gap-fill pricing in order to process the new MoPath Tier I and Tier II codes.

Q: Is there a law that says MACs must pay all clean claims within 30 days?

A: It is a performance requirement to process clean claims timely, but not a law. Any clean claim paid after 30 days includes interest payments.

Q: What percentage of the total invoices submitted to Palmetto for molecular tests since January 1 have been paid to date?

A: Unfortunately, we’re unable to provide that level of detail. But, we can share that Palmetto is processing and paying clean claims without undue delay.

Q: When can labs expect to be paid in full for molecular test invoices submitted since January 1?

A: Again, not applicable to us as we’re processing and paying clean claims without undue delay.

Q: Has Palmetto posted all prices for molecular tests?

A: We’ve priced and published all Tier I/II codes with claims in our processing jurisdictions. Some unique ‘panels’ and other combinations, which will need to be submitted using NOC codes, are being finalized this week. We’re in direct communication with those laboratories.

Q: Will Palmetto revise prices posted so far or are they final for the year?

A: The gap-fill process includes a CMS posting for comment and we will review the comments. Any data submitted that might require reconsideration could result in revised pricing.

Q: Is Palmetto setting prices for all the MACs nationwide?

A: We’re only responsible for establishing gap-fill pricing for our jurisdiction. We’ve used the data available through our MolDX program to facilitate our review. We’ve also shared our pricing with the other MACs. But, it’s important to remember that each MAC is to conduct its own review process and submit to CMS for consolidation.

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