Here come the Big MACs

Thursday, March 31, 2005

Q. We've always known that dealing with the DMERCs was sometimes a real whopper. But what's this about a Big MAC in all of our futures?
A. Although DME benefit expenditures for Medicare are small in comparison to Medicare expenditures for other benefits, the Medicare program has been focusing a lot of attention on suppliers recently. Several announcements from CMS last month indicate that suppliers will not get respite from this activity any time soon.
CMS announced that it will begin a contracting reform initiative by competitively bidding its DMERC contracts. This competition will result in a new Medicare claims processing entity, the Medicare administrative carriers – or “MACs.” Under the CMS’ timeline, the new MACs will be announced by the end of the year.
Monitoring the transition to the MACs is a big job on its own, but CMS has also begun to implement a new appeals process that will coincide with the change in carriers. The MACs will have responsibility for paying claims and performing initial reviews. Appeals from those decisions will go to new contractors – the qualified independent contractors, or “QIOs” – whose primary function will be to conduct fair hearings. You may recall that the MMA also calls for the transition of the ALJs to HHS. The ALJ transition begins later this year, and the new appeals process will apply to suppliers starting in January 2006.
Those are a lot of changes in the area of claims, audits and appeals at one time. But consider that these changes also coincide with the implementation of the new power wheelchair codes and that the transition from the DMERCs to the MACs will likely coincide with the first rounds of competitive bidding in 2007. The supplier community will need to remain very vigilant to make sure that these changes are done correctly.


Asela Cuervo is the principal in the Law Offices of Asela Cuervo in Wasgington, DC: 202.496-1281