Determining Medicare Coverage
For people with Medicare, there are a number of situations where their provider, health plan administrator, or other healthcare professional may need to confirm their coverage details. Perhaps they need a specialty service, so the provider checks to make sure it is covered. Perhaps the health plan needs to ensure a service was medically appropriate, so they check the determination. Or maybe the plan requires prior authorization for a given service before it is administered (as is common for Medicaid and Medicare Advantage plans). In many of these situations, answers can be found in the coverage determinations provided by the Centers for Medicare & Medicaid Services (CMS) and their associated Medicare Administrative Contractors (MACs).
NCDs, LCDs, NCAs, and Memos
When searching for Medicare determinations, the process has many layers, and finding appropriate guidance can be difficult. In addition to Medicare’s National Coverage Determinations (NCDs), which apply across the U.S., MACs also release Local Coverage Determinations (LCDs) for regional jurisdictions. In addition to keeping track of which determinations appear where, the policy determinations come out at irregular intervals, making it difficult to keep abreast of the newest information.
Given the significance of NCDs, they are continually re-examined and updated through a process known as National Coverage Analysis (NCA). If an NCA results in a new or updated NCD, the change is communicated via a Final Decision Memo, which immediately becomes the new official CMS policy. However, those changes are not reflected in the NCD itself for up to a year (and nothing in the current NCD will indicate that a change has been made). Hence, it can be challenging to know when a determination has been retired or superseded.
Service Not Found
In addition to sifting through the plethora of Medicare documents to identify which determinations are current for a given region, there’s also the challenge of actually finding a ruling on the specific service needed. In the past, it was possible to use Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes to search on the CMS website. In 2019, in an effort to make local and national coverage processes more uniform, CMS released Change Request 10901, which required all Medicare Administrative Contractors (MACs) to begin removing all codes from the LCDs. The codes can now only be found in a separate document called a Local Coverage Article (LCA). An inconvenient result of this change is that it’s now impossible to search for coverage determinations by CPT or HCPCS code on the CMS website.
Finding a Tool to Support Efficiency and Medicare Compliance
Fortunately, there is a solution healthcare professionals can leverage for Medicare determinations from MCG Health, a trusted industry leader in evidence-based care guidelines. The MCG Medicare Compliance solution cuts through the extra layers to optimize the search experience for Medicare coverage determinations. It is a comprehensive offering which includes all NCDs and LCDs, retains the ability to search determinations by CPT or HCPCS codes, and goes a few steps beyond to bring all the pieces together. When a Final Decision Memo indicates an upcoming change, MCG updates the appropriate NCD in a timely manner. For LCDs that are no longer in effect, MCG provides indicator badges which identify them as “Retired” or “Superseded” to minimize confusion while allowing for flexibility and accuracy in retrospective reviews. The content is updated regularly to maintain alignment with CMS, and it’s managed with the same attention to detail by the same physician editor team that publishes MCG’s world-class, evidence-based care guidelines.
How Can Healthcare Companies Benefit?
There are a variety of ways that healthcare professionals can benefit from using MCG Medicare Compliance throughout a member’s journey of care.
For Payers, ACOs, Or Shared Risk Entities:
- Can be used by utilization management (UM) teams to review services and help ensure they are appropriate (based on CMS and MAC determinations)
- Can be used for prior authorization of procedure requests (for Medicare Advantage and Medicaid only)
- Can be used to evaluate outlier provider or service in fraud and abuse audits
For Government Contractors (QIOs, UPIC, SMRC, Recovery Auditors):
- Can be used by Medical Review Teams to review services and help ensure they are appropriate (based on CMS and MAC determinations)
- Can be used to evaluate outlier provider or service in fraud and abuse audits
MCG also makes the Medicare Compliance solution available through its interactive software, Cite CareWebQI, to support clinical decision-making. This solution can provide access to MCG care guidelines covering the full spectrum of care to facilitate real-time care planning and review. Cite CareWebQI can also integrate with many industry-leading medical management and utilization management platforms.
In addition, Medicare Compliance is available for use within MCG Cite AutoAuth, which goes a step further by enabling plans to automate medical necessity review as part of the request submission workflow. The web-based interface, provided through a payer’s portal, makes it easy for a provider to document and support treatment requests. It can also be customized to support a payer’s business and medical policy rules. AutoAuth even matches the payer’s specific criteria to the clinical information and attached guideline content, making it possible to authorize the procedure or admission automatically.
Learn more and request a demo of MCG Medicare Compliance by reaching out to MCG.
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