The CAP and ten other health care professional organizations urged the Centers of Medicare & Medicaid Services (CMS) to increase transparency and clarify stakeholder engagement in the medical coverage determination process. The groups have raised these concerns with Medicare Administrative Contractors (MACs) over the past several years and asked the CMS for wholistic changes to the process. The CAP has advocated for fair medical coverage changes to in the medical coverage determination process.

In a January 18 letter to the CMS, the groups raised concerns regarding lack of transparency and deteriorating and haphazard stakeholder engagement in the medical coverage determination process. In the letter, the groups said, “our organizations are concerned that MACs are establishing policy without providing adequate opportunity for notice and comment.” The groups outlined how the

CMS should include transparency and stakeholder engagement by:

• Increasing opportunities for public notices and comments;
• Clarifying contractor advisory committee engagement; and
• Improving transparency regarding coverage policies.

The groups asked the CMS to ensure that “any new local coverage articles, or any updates reflecting non-routine changes in coding, are subject to notice and comment; require MAC contractors to provide a public notice period before new or revised new local coverage articles take effect; and that the CMS must ensure meaningful engagement of the CAC representatives through policies that establish minimum meeting frequency requirements for the full CAC to meet, and minimum CAC member participation thresholds, and requirements for MACs to provide CAC representatives opportunity to review and advise on evidence prior to the issuance of a draft local coverage determination. The CMS should also require contractors to allow all CAC representatives to comment, ask questions, and actively participate during multi-jurisdictional CAC meetings.”

The groups also asked the CMS to revise Chapter 13 of the Medicare Program Integrity Manual to provide better clarity regarding timelines for developing and issuing draft LCDs following a request for a new LCD or a reconsideration request.

The CMS announced in October 2018 the revision of Chapter 13 of Medicare’s Program Integrity Manual, which addresses LCDs. The revisions were in response to legislative requirements and comments from stakeholders, like the CAP. While the CMS adopted some of the CAP’s recommendations in the updated manual, the CAP continues to advocate for additional changes.