Bill would formalize LCD process

Friday, October 14, 2016

WASHINGTON – A bill recently introduced in the Senate that seeks to improve how the Medicare Administrative Contractors develop local coverage determinations is more of a message bill when it comes to HME, stakeholders say.

The bill, which would, among other things, require the MACs to disclose their rationale for LCDs, is geared more toward other Part B services, not DMEPOS, AAHomecare’s Kim Brummett says.

“There would be some (positive) ramification for DMEPOS,” said Brummett, vice president of regulatory affairs. “It would force the MACs to be more transparent in LCD revisions and creation, which isn’t a bad thing.”

The bill also seeks to: require open and public meetings with the MACs that are on record; provide stakeholders with a meaningful reconsideration process for LCDs; and prohibit the MACs from adopting LCDs from another jurisdiction without first conducting its own evaluations.

The MACs already meet most of the provisions in the bill—in practice, says consultant Andrea Stark. A recent draft policy for surgical dressings, for example, lists the rationale behind the policy in a section titled, “Sources of Information and Basis for Decision,” which comprises 17 researched items.

“The major (provisions), in my opinion, are for the most part already taking place on the DME side,” said Stark, a Medicare consultant and reimbursement specialist.

One of the forces behind the bill, the Advanced Medical Technology Association, acknowledges its main goal is to formalize existing practices.

“We’re concerned because the provisions are not statute, they’re just in the manuals,” said Chandra Branham, vice president of payment and health care delivery policy for AdvaMed. “This gives CMS the flexibility to tinker with the process.”

That’s exactly what CMS did a few years ago, AdvaMed says, when it proposed to make changes to the LCD for diagnostic tests, changes that were never formalized.

“In an attempt to streamline the LCD, they stripped out the protections in the current process,” Brantham said.

The bill does go above and beyond existing practices in a few areas, including requiring CMS to appoint “a Medicare Reviews and Appeals Ombudsman to carry out specified duties with regard to LCDs.”

“In the process of attempting to formalize (the LCD process), we have offered some additional requirements that aren’t in the manuals,” Brantham said.