The trusted source for
healthcare information and
The newly renamed Centers for Medicare and Medicaid Services (CMS) will implement three new programs designed to make the agency more responsive, efficient, and accessible, says administrator Thomas Scully, head of what formerly was the Health Care Financing Administration.
The new programs include:
• open door policy committees, chaired by senior level staff, including Scully, that will meet monthly with provider and beneficiary groups to give them a better understanding of, and access to, policy input;
• regional listening forums open to the public so they can hear about the daily effects of CMS regulations from physicians and HMOs;
• in-house expert teams across CMS’ program areas to think about new ways of doing business to reduce administrative burdens and simplify regulations to make Medicare more "user-friendly."
"We have an enormous health care system with a lot of problems . . . I think we can improve [with] a list of things we can fix monthly," Scully says.
One area of long-time contention CMS has just acted on is a clarification of the duties of Medicare contractors in developing local payment policies that are included in changes to the Medicare Program Integrity Manual (Transmittal No. 8). The manual update is intended to help providers understand why claims are paid or denied. It discusses circumstances under which Medicare contractors should issue new or revised local medical review policies (LMRPs). Changes required by the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 will be covered in a separate transmittal.
LMRPs are developed by contractors to make coverage decisions in their jurisdictions. According to the manual, LMRPs "are used to make local medical coverage decisions in the absence of specific statute, regulations, or national coverage policy, or as an adjunct to a national coverage policy."
Under these changes, contractors are to develop LMRPs when they have identified an item or service that is never covered and wish to establish automated review in instances where there is no national coverage decision. Contractors are also encouraged to develop an LMRP when:
— a "validated widespread problem" threatens Medicare funds;
— a contractor has assumed the work of another contractor and is attempting to make policies uniform across jurisdictions;
— frequent denials are issued or anticipated involving certain issues.
Contractors must review and revise LMRPs within 90 days of when a program instruction containing a new or revised national coverage decision is issued, when a new or revised coverage provision in an interpretive manual is published, and when a program instruction containing a change to national payment policy is issued.
As of Oct. 1, contractors must review all LMRPs annually to ensure consistency with national coverage decisions, changes in manuals, and other documents. "If an LMRP has been rendered useless by a superseding national policy, it must be retired," according to the transmittal. Other changes in the transmittal include requirements that contractors:
— name a medical review manager that will act as the primary contact between the contractor and CMS;
— attempt to develop uniform LMRPs across all their jurisdictions;
— use less stringent evidence when allowing for coverage of services that have lower risks of negative health effects on beneficiaries.