07/28/2026
HOLD YOUR HORSES...DON'T START CRUNCHING NUMBERS YET
After my last post, I've had several people ask, "Okay Don, how do we calculate that first criterion?"
Well...before you saddle up and spend half the afternoon pulling reports out of your practice management system, let me save you some work.
You may not even need to calculate it.
Yep...you read that right.
Most folks are starting at the wrong end of the wagon.
Before I spent one minute trying to separate Traditional Medicare from Medicare Advantage or figuring out which dollars went where, I'd ask one simple question:
Did your practice receive at least $12,500 in Traditional Medicare payments under the Clinical Laboratory Fee Schedule (CLFS)? Stop - I don't care about the money you've received from Medicare Part C plans on lab services. That is not calculated here, only count what your Traditional Medicare has paid you on lab.
If the answer is no, you can put your calculator back in the drawer.
Why?
Because if you don't meet that requirement, you don't qualify as an Applicable Laboratory under PAMA. There's no reason to spend the next three hours trying to calculate the other criterion.
That's what I see a lot of physician offices getting ready to do.
They're fixing to spend hours calculating something that may not even matter.
I'd much rather eliminate the easy question first.
If you don't hit the $12,500 Traditional Medicare CLFS threshold, you've saved yourself a whole bunch of work.
Then—and only then—would I fool with the other calculation.
Sometimes Medicare isn't hard because the regulations are complicated.
Sometimes it's hard because folks start at the wrong end of the problem.
