ACR challenges lack of transparency in Medicare Administrative Contractor coverage determinations
The American College of Radiology is joining 17 other provider groups in challenging the lack of transparency in how Medicare Administrative Contractors reach local coverage determinations.
ACR and others voiced their concerns in a recent letter to Centers for Medicare & Medicaid Services leadership. Back in 2018, the agency revised its policies governing how new coverage policies are developed and determined. But the groups have continued to experience challenges navigating the process, including a lack of opportunities to comment or hold MACs to specific timelines.
“Sound coverage development and implementation processes support Medicare beneficiaries’ access to medically necessary and appropriate healthcare services,” ACR and others wrote to Lee Fleisher, MD, chief medical officer and director of the Center for Clinical Standards and Quality. “However, our experience leads us to have concerns regarding lack of transparency and deteriorating and haphazard stakeholder engagement, as further detailed below.”
In particular, as providers wait for MACs to make local coverage determinations, there are several stages in which there is no specified timeline. A contractor has 60 days to determine if a local coverage determination request is complete. Yet after that there is no established timeframe for MACs to issue a draft coverage determination. The college and its colleagues also decried a lack of public notices in these processes and corresponding opportunities to comment.
And while CMS has established advisory committees to serve as a “vital link” between contractors and providers, the relationship has eroded since the process was revised a few years ago. Meetings occur less frequently, at inopportune times, or in more difficult-to-reach locations.
“Meaningful engagement by [Contractor Advisory Committee] representatives enables contractors to benefit from the education, experience, and expertise of individuals who engage in patient care on a daily basis and can put evidence into context based on their practice area,” ACR and others wrote. “Failure to uphold the advisory role of CAC members can result in reduced access to care, harm to Medicare beneficiaries, and unnecessary burden on health care practitioners.”
The groups issued a list of six recommendations to fix the process. Those include requiring contractors to provide a public notice period ahead of changes in coverage policies, and publicly reporting performance metrics to hold MACs accountable for adhering to key timelines. You can read the full letter here. Others signing the note included the American College of Surgeons, the Coalition of State Rheumatology Organizations, and the College of American Pathologists.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.