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Special Report: September 12, 2018

House Passes Transparency Reforms to Medicare’s Local Coverage Program

As LCD reform bill moves to Senate, the CAP expresses concern with the House’s removal of key provisions to weaken the bill

The House of Representatives passed the Local Coverage Determination Clarification Act, which aims to improve accountability and transparency in the process Medicare contractors use to make local coverage decisions. The legislation passed the House by a voice vote on September 12.

The CAP had strongly advocated for reforms in the original legislation, which would ensure local coverage determinations (LCDs) by Medicare contractors are made by qualified health experts, through a transparent process, based on sound medical evidence.

Key provisions in the bill approved and/or modified by the House include:

  • Open and recorded Medicare Administrative Contractor (MAC) Carrier Advisory Committee meetings.
  • Upfront disclosure of evidence the MACs consider when drafting an LCD, as well as the rationale they are relying on to deny coverage.
  • Additional options for challenging an LCD.
  • Annual reports to Congress on the number of LCD appeals and actions taken in lieu of the creation of an ombudsman.

The House weakened key provisions sought by the CAP that would:

  • Require MACs to independently review LCDs and prevent contractors from rubberstamping another contractor’s LCD.
  • Create a meaningful appeals process that requires a qualified third party make decisions about the validity of reconsideration requests.

CAP President R. Bruce Williams, MD, FCAP expressed disappointment that the House has weakened the bill, but he thanked Reps. Lynn Jenkins (R-KS) and Ron Kind (D-WI) for introducing and advocating for the Local Coverage Determination Clarification Act. Dr. Williams urged the Senate to ensure the bill’s original provisions are preserved, which will further protect patients from arbitrary decisions to deny coverage for Medicare services.

“With the reform legislation moving to the Senate, senators now must maintain key provisions to stop Medicare contractors from rubberstamping coverage decisions and using the LCD program to circumvent the more rigorous requirements of the National Coverage Determination process,” Dr. Williams said. “These safeguards are needed to protect Medicare patients from flawed LCDs and ensure Medicare administrative contractors base all their coverage decisions on sound scientific evidence and advice from local physicians and other health care professionals.”