Analysis of Lecture
Reimbursement 101 Medicare Basic Reimbursement: Program Overview and Updates for 2019 Coverage Determinations Coverage determinations determine whether a benefit exists for a specific product or service, and are for items and services that are reasonable and necessary for the diagnosis or treatment of a specific illness or injury. Coverage of a specific product or service does not necessarily guarantee payment from a Payer, they are more likely to be a reimbursable or payable for the service or product. Medicare coverage determinations can occur at both a federal and a local level. National Coverage Determinations (NCD) are handled by the CMS Central Office Local Coverage Determinations (LCD) are handled by Medicare Administrative Contractors (MAC) (NDC) (LCD) Pathways to Coverage Medicare can determine coverage for physician administered medications at both a national and local level. NCD decisions are binding on all Medicare contractors, and the LCD policy cannot be more restrictive than the NCD, however it can be less restrictive National vs Local Coverage CMS NDC Local Contractors Program Memoranda & Manuals LCD & LCD Articles Case by Case Determinations Coverage Bulletins & Newsletters How Medicare Implements Coverage Determinations HowNCD •All Medicare Contractors at local level are nationally bound •Not commonly used for creating drug policies by CMS Program Memorandum & Manuals •All Medicare contractors at local level are nationally bound •Statutory requirements are usually the basis for policies LCD Articles •Locally binding at MAC jurisdiction level •Could provide billing and coding information for services or drugs •Could provide conditions in which services could be covered such as medical vs. pharmacy Local Coverage Bulletins •Information that is locally binding for individual MAC jurisdiction level •Can provide clarifications and/or direction regarding medical coding and billing, claims processing, and specific directives for processing National Coverage Determinations (NCD) NCDs are less common than local coverage decisions for physician administered drugs Most decisions provided at a local jurisdiction level are created by the medical personnel at the MAC. This usually occurs due to the lengthy and rigorous process that it takes for a determination at a national level to be approved. The typical timeframe for a National Coverage Determination to approved is approximately 5-9 months in duration. Medicare, however does see it necessary at times to develop a NCD for a specific item or service that will be applied on a national basis. Some of the reasons that Medicare deems this necessary are that the LCDs are not consistent with each other, a new service supports a medical advance, down to program integrity concerns have arose under local or national policy. Key Advantages and Disadvantages of an NCD Some of the advantages of having an NCD are that there is more of an intense review process for an in-depth root-cause analysis of the current or potential benefit and its impact on the program, there is more of an evidence based review process in order to make the determination is the best one, there is more consistency amongst the MACs based on the determination, and favorable decisions will facilitate across all contractors. However, with all of the favorable advantages of a National Coverage Determination, there are many disadvantages as well. Some of the disadvantages are that these determinations are reserved for more major items that pose to be controversial or that could potentially have an impact on the program, they need to have strong clinical evidence to support the determination, and that negative determination will affect all MCA contractors. Local Coverage Determinations (LCDs) The LCD information is available on both the contractor website as well as the CMS website for easier access In the absence of a NCD, the local jurisdiction can create a LCD establishing when a service or product will be covered A LCD does require a formal process that typically takes 6-9 months for a new determination, however, a formal process is not needed for a minor change to an already existing LCD. There is a 6 step process for a new determination which includes, the contractor drafting the LCD, an open meeting held for the public usually 4-5 times a year, A Contract Advisory Meeting, the drafted LCD being available to the public for 45 days for public comment, the review of public comments taken into consideration by the contractor, and then finally the LCD is posted 45 days prior to its implementation. Key Advantages and Disadvantages: LCDs and Case-by-Case There are many advantages such as more of a short term process than a NDC and can be issued more quickly to confirm coverage or provide information and coding guidance Newsletters and bulletins can be independent of LCD, and guidance is usually confined to a specific contractor jurisdiction Case by Case determinations take the patient specific situations into account and are available immediately upon their launch However there are some disadvantages as well such as, a potential for variations of coverage’s across contractors, building rapport and relationships with a contractor can be difficult and time consuming, there is no formal comments process, as well as initial claim denials and delays for case by case determinations due to medical review personnel not having an opinion formed on the specific matter at that time. Conclusion Questions ? References cms.gov medicare.gov aace.com aapc.com Evaluates how educational theory is demonstrated in lesson tasks and strategies and identifies criteria used to evaluate. Analyzes effectiveness of selected learning tasks using student data and evaluates the quality of the data Evaluates how professional research is demonstrated in lesson tasks and strategies and considers gaps in the literature. Analyzes how lesson tasks demonstrate an equitable, inclusive learning environment and identifies assumptions on which tasks were based.
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