PDFWAC 182-531-0850
Laboratory and pathology physician-related services reimbursement.
(1) The agency pays for clinical diagnostic laboratory procedures based on the medicare clinical laboratory fee schedule (CLFS). The agency obtains information used to update fee schedule regulations from the CMS CLFS website.
(2) The agency updates budget-neutral fees each year by:
(a) Determining the units of service and expenditures for a base period. Then,
(b) Determining in total the ratio of current agency fees to existing medicare fees. Then,
(c) Determining new agency fees by adjusting the new medicare fee by the ratio. Then,
(d) Multiplying the units of service by the new agency fee to obtain total estimated expenditures. Then,
(e) Comparing the expenditures in (d) of this subsection to the base period expenditures. Then,
(f) Adjusting the new ratio until estimated expenditures equals the base period amount.
(3) The agency calculates maximum allowable fees (MAF) by:
(a) Calculating fees using methodology described in subsection (2) of this section for procedure codes that have an applicable CLFS.
(b) Establishing RSC fees for procedure codes that have no applicable CLFS.
(c) Establishing maximum allowable fees, or "flat fees" for procedure codes that have no applicable CLFS or RSC fees.
(d) If appropriate, the agency may adjust fees using market research. The agency reimbursement for clinical laboratory procedures does not exceed the regional CLFS.
(i) "Market research" means the systematic collection and analysis of relevant and verifiable data related to the health care marketplace, including commercial benchmarks, medicaid rates from other states, and relevant economic indicators.
(ii) Market research will be appropriate when a material change in market conditions is demonstrated or is directed by the legislature.
(4) The agency may change fees based on legislative direction. If the legislatively authorized change becomes effective at the same time as the agency's annual update, the agency applies the change after calculating budget-neutral fees, if applicable.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 25-10-082, s 182-531-0850, filed 5/6/25, effective 6/6/25. WSR 11-14-075, recodified as § 182-531-0850, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0850, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 01-01-012, § 388-531-0850, filed 12/6/00, effective 1/6/01.]