Ask the DMERC MDs

Wednesday, November 30, 2005

Recently, we discussed a variety of issues surrounding Medicare's national coverage determination for mobility assistive equipment. Mobility issues will continue to be an important item in this column; however, there are other things occurring in the world of the DMERCs to stay informed about. This month we will discuss contractor reform and its impact on the DMERC contractors.
Q. I have seen notices about changes in the DMERC contractors. New PSCs have been announced. DME MACs are coming. What is this all about?
A. Traditionally, CMS has contracted with insurance companies to perform the tasks necessary to administer the Medicare program. Claims processing, customer service, provider education, medical review, MSP, medical policy, and fraud and abuse tasks have all been the responsibility of a single contractor for a given jurisdiction. The original four DMERCs were examples of this approach to contracting.
In recent years, CMS has shifted its contracting approach away from a single general contractor to multiple specialty contractors. Specialty contractors handle specific tasks within a given jurisdiction. Multiple contractors may work together to provide the full range of necessary services for a jurisdiction. The current arrangement in Region A is a good example of this type of contracting. In 2001, the workload was split between two contractors. HealthNow New York, called the affiliated contractor or AC, continued its responsibilities for claims processing, customer service, MSP, provider education, etc. Tricenturion, the program safeguard contractor or PSC, handled the benefit integrity, medical review and medical policy workload.
Earlier this year, CMS decided to do two things in the name of contracting reform that will affect the DMERCs: First, Regions B, C, and D were split into the full PSC model used in Region A; second, CMS decided to put all of the DMERC-ACs up for bid.
The following DMERC PSC changes are under way. Tricenturion retains its contract for Region A and adds the Region B states to its jurisdiction effective March 1, 2006. The PSC for Region C has not yet (as of this writing) been selected. Bidding is currently under way for Region C. A decision is anticipated in early December. Region D PSC workload will be assumed by EDS, with IntegriGuard as a sub-contractor performing medical review functions, effective March 1, 2006.
The DMERC AC bidding process is currently under way. Decisions are expected in December 2005. The new contractors will be called DME Medicare Administrative Contractors or DME MACs. The DME MAC boundaries will shift slightly from the existing regional boundaries to correspond with 15 Part A/B MAC regions that are being created.
Region A will add Maryland and the District of Columbia
Region B will add Kentucky
Region C will add Virginia and West Virginia
Region D remains unchanged
The DME MAC transition is scheduled for completion by July 1, 2006.
Q. How will this transition affect my day-to-day business?
A. Based upon our experience with the previous Region A PSC transition, most suppliers should be unaffected. It is only in the event of medical review, local provider education and training or investigation that a supplier will interface with a DME PSC.
Information regarding the impact of the DME MAC transition will be forthcoming once the selection process is complete.
In the meantime, providers can find additional information about contracting reform at this CMS web site:

<a href=&#39; &#39;>