In response to concerns over perceived lack of transparency and deteriorating stakeholder engagement on the part of Medicare Administrative Contractors (MACs) in the process of developing Medicare local coverage determination (LCD) policies, a number of medical societies jointly urged the Centers for Medicare & Medicaid Services (CMS) to make changes to these processes. A total of 18 medical organizations signed on in support of this request, which was spelled out in a letter sent this month to Lee Fleisher, MD, Chief Medical Officer and Director at CMS's Center for Clinical Standards and Quality.

The societies cite as a particular concern what they view as a serious erosion of MAC engagement with local Contractor Advisory Committees (CACs). The CACs historically engaged effectively with contractor medical directors (CMDs) and other MAC officials. But, according to the societies, under revised policies put into place in 2018, the CAC meetings are now occurring less frequently and are scheduled haphazardly.

Further, the societies cite a lack of transparency in the LCD development and reconsideration processes. They note that MACs are increasingly working collectively across jurisdictions to convene panels of subject matter experts on policies of interest, but that there is little clarity on when and how such panels are convened, or how individuals are selected to serve in these roles.

To address their concerns, the medical societies offer the following specific recommendations:

• CMS should ensure that any new local coverage articles, or any updates reflecting non-routine changes in coding, are subject to notice and comment.
• CMS should require MACs to provide a public notice period before new or revised local coverage articles take effect. 
• CMS should ensure meaningful engagement of CAC representatives through policies that establish minimum meeting frequency requirements for the full CAC and minimum CAC member participation thresholds. CMS should also require that MACs provide CAC representatives opportunity to review and advise on evidence prior to the issuance of a draft LCD. And, CMS should require MACs to allow all CAC representatives to comment, ask questions, and actively participate during multi-jurisdictional CAC meetings. 
• CMS should update Chapter 13 of the Medicare Program Integrity Manual to provide greater clarity and transparency regarding timelines for developing and issuing draft LCDs following a request for a new LCD or a reconsideration request. MACs should be required to issue draft LCDs within 180 days of a determination that a request is complete or valid. 
• CMS should require contractors to notify all CAC members of the convening of expert panels and to offer CAC representatives the opportunity to work with their societies to nominate panelists. MACs should also apply objective criteria in the vetting and selection of experts.
• CMS should implement and publicly report performance metrics that hold MACs accountable for adhering to applicable LCD timelines, standards for CAC engagement, and other process improvements.

Kudos to these medical societies for not only raising concerns about how Medicare local coverage policies are being developed, but also for making specific recommendations on how to improve the processes by which these changes are considered by ensuring appropriate provider input.