SCHAENING ACP KEYNOTE: 2019 LCD DRAFTING, NOTIFICATION, REVISION TO BE MORE TRANSPARENT
By Vanessa Salvia
Juan Schaening, MD, the executive contractor medical director for Medicare Jurisdiction N, discussed changes to 2019 Local Coverage Determinations during a keynote address at the American College of Phlebology’s 32nd Annual Congress Nov. 9 in Nashville. He said changes are designed to provide transparency in the processes for notifying stakeholders of proposed revisions to and drafting of new LCDs.
The Jurisdiction N MAC annually issues $19.5 billion dollars of Medicare Part A and Part B benefit payments for Florida, Puerto Rico and the Virgin Islands. For the past 14 years Dr. Schaening has held the positions of Puerto Rico Medicare Part B Carrier medical director, Jurisdiction 9 and Jurisdiction N MAC medical director. He is a former chief medical director of the Puerto Rico Correctional Health Service Program.
LCDs are decisions made by a Medicare Administrative Contractor (MAC) whether to cover an item or service in a MAC’s jurisdiction (region) in accordance with section 1862(a)(1)(A) of the Social Security Act. The MAC’s decision is based on whether the service or item is considered reasonable and necessary.
Primary concerns had previously centered on the fact that there was little transparency in notifying stakeholders of proposed revisions to and drafting of new LCDs. Stakeholders were also concerned that the process of receiving, soliciting and providing feedback on LCDs was ineffective.
The 2016 21st Century Cures Act included changes to the LCD process, adding language to describe the LCD process. “Changes based on the 2016 21st Century Cures Act requires transparency on how they make Medicare coverage decisions and it says that they need to involve stakeholders and give them an opportunity to see the process and participate,” said Dr. Schaening.
His most important message was that once the LCDs go through the approval or non-approval process they are not written in stone. Stakeholders can submit requests to have the decision reconsidered. Under the new process, the request will be evaluated, and the stakeholder will receive a note of whether the reconsideration request is valid or not valid within 60 days. “If it’s valid we’ll put that on the priority list and will review it again,” said Dr. Schaening.
The board will review literature and discuss the evidence before making their decision. Dr. Schaening said that ACP member guidance will be considered in the summary of consultation. “Through this process we will have more participation from the societies that should result in a better understanding of the coverage that should result in less denials of your claims and obviously less provider burden,” he said.
The new process provides for an open meeting along with a four-month comment period. Then they draft their final LCD based on any comments they receive during that period. Then they are posted on the website for 45 days. During that 45 days, stakeholders have time to evaluate any impact of the decision, and on the 46th day the decisions becomes effective and start impacting the claims that physicians submitting to the MAC.
The current changes were opened for comment Oct. 3, 2018 and will be implemented Jan. 8, 2019.
During a brief question and answer period and panel discussion, Dr. Schaening responded to questions about discrepancies in coverage; for instance, discrepancies in coverage when patients cross the border from New York into New Jersey or vice versa. He also acknowledged that consulting experts could be considered societies of physicians similar to the members of the ACP. Dr. Schaening said that when they consult, they’ll start with experts among their Contractor Advisory Committee (CAC) members. If they have a representative that is not as knowledgeable as necessary, that representative will recommend someone, and they now have a new model to consult societies.
The new CAC will document what specialties or societies were consulted and make that a permanent part of the document. Further to that point, ACP board member Chris Pittman, MD, questioned whether it was necessary for the ACP to restructure its national organization to get statewide representatives to meet the requirements of the MAC’s CAC. Dr. Schaening assured that no, that was not necessary.
“Our take is that we want representatives of national societies and the requirement of the changing instructions that CMS gave us is that you should have representation of someone doing business in your jurisdiction of health providers, and CMS gave a lot of leeway,” Dr. Schaening said. “But the way that we are planning to administer that is if you have a national society and someone who wants to participate and you as the society are recommending one, we will consider him to enter our CAC. If you have an ACP member that is practicing in Florida and he has the backing of the ACP, then we will consider him.”
Dr. Marlin Schul, a panelist and leader in the development of the ACP PRO Venous Registry, summed up the experiences of those listening to Dr. Schaening’s speech: “Sometimes we get bombarded with decisions that don’t make any sense, but with these changes it sounds like a glimmer of hope on the horizon for the future.”
Jurisdiction N is part of GuideWell Source, which owns First Coast Service Options Inc., Novitas Solutions Inc. and GuideWell Allegiance Inc. First Coast is the Part A and Part B Medicare Administrative Contractor (MAC) for Florida, Puerto Rico and the U.S. Virgin Islands (Jurisdiction N). Novitas is the MAC for northeastern and south-central states. As MACs, First Coast and Novitas represent approximately one-third of the entire Part A and Part B Medicare landscape.
First Coast and Novitas provide administrative and claims processing services for state and federal health care programs such as Medicare and Medicaid for more than 11 million beneficiaries.
Medicare is 15 percent of the American budget. It represented $425 billion in 2007 and is $702 billion as of 2017. Jurisdiction N handled 373 million claims to the Medicare program and between the two companies is paying $110 billion. As the medical director for the Florida Medicare Contractor, Dr. Schaening shared some of their perspectives on how they see venous and lymphatic disease being treated and billed. VTN