WOCN Supports Legislation to Reform Local Coverage Determinations
Legislation has been introduced in Congress to reform how Medicare Administrative Contractors (MACs) determine how they will pay for services. MACs are private entities contracted by Medicare to process claims and make reimbursement decisions on medical items and services. There are 12 MACs for Medicare's hospital and office based services providing Medicare coverage across the country. In recent years, MACs have shown a pattern of making coverage decisions that are void of current practice methodology, lack provider input, and are not in the best interest of patient care.
S.794, the Local Coverage Determination Clarification Act of 2017 introduced by introduced by Sens. Johnny Isakson (R-Ga.), Tom Carper (D-Del.), Debbie Stabenow (D-Mich.), and John Boozman (R-Ariz.), would help restore balance to the LCD process by making the following changes:
1. Open Meetings: Requires that Medicare Administrative Contractors' (MACs) Carrier Advisory Committee (CAC) meetings be open, public, and on the record. Minutes taken and posted to the MAC's website for public inspection. Requiring these increased levels of transparency will facilitate an improved forum for information exchange between MACs and interested parties.
2. Upfront Disclosure: Requiring MACs to include - at the outset of the process - a description of the evidence the MAC considered when drafting an LCD, as well as the rationale they are relying on to deny coverage.
3. Meaningful Reconsideration and Options for Appeal: Creating an appeals process for providers and suppliers to appeal a MAC's decision to CMS. Under current Centers for Medicare & Medicaid Services (CMS) rules, MAC LCDs are essentially unreviewable once they become final. S.794 gives providers and suppliers an opportunity to have a qualified third party make a decision about the validity of their reconsideration requests in limited circumstances.
4. Stopping the Use of LCDs as a Backdoor to NCDs: Prohibiting CMS from appointing a single MAC, either expressly or in practice, from making determinations to be used on a nationwide basis in a given specialty. The CAP has witnessed the carbon copy adoption of LCDs by other MACs without the benefit of meaningful solicitation or independent assessment of comments and concerns from the public or medical community of the adopting MAC. This has the practical effect of establishing national coverage policies without having followed the more rigorous national coverage determination (NCD) requirements.
5. Creating an Ombudsman: Creating an Ombudsman to provide providers and suppliers with administrative and technical assistance in filling appeals, make publicly available information about the number of appeals filed with the MAC and with CMS each year, the actions taken by the MACs with respect to appeals filed, the number of times the Secretary took action in response to appeals filed with HHS, responsiveness of the MACs, and providing recommendations to the Secretary on ways to improve the efficiency of the appeals process.
The Society has become very concerned about how these LCDs will impact patient care in the future and have endorsed S. 794. Our letter of support can be found here. The Society recently submitted comments to two contractors (First Coast Option & Novitas Solutions) who have proposed concerning changes to wound care policies in separate LCDs.