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George Waldmann, M.D. . Contractor Medical DirectorCarrier Advisory Committee February 2006 . CMD Initial History . HCFA ordered each state to have Carrier Medical Director (CMD) in 1987. CAC Initial History. HCFA ordered formation of Carrier Advisory Committees (CAC) in 1992
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1. Carrier Advisory Committee (CAC) History
Function
Value
Future
2. George Waldmann, M.D.
Contractor Medical Director
Carrier Advisory Committee
February 2006
3. CMD Initial History HCFA ordered each state to have Carrier Medical Director (CMD) in 1987
4. CAC Initial History HCFA ordered formation of Carrier Advisory Committees (CAC) in 1992
Defined members, chairpersons, functions
5. CAC Initial History Mission to foster better relations & trust between carriers and providers
Advisory capacity only
6. CAC Initial History Influence policy development at the
local level
No funds allocated by HCFA for CAC
Standardized format
7. CAC Evolution Provide local “flavor” to policy
development
Publishing of Draft LCD/LMRP
Draft LCD/LMRP now available on website
Open or “pre-CAC” meeting available
for non CAC members
8. CAC Evolution Now more effective
Informational vehicle
Venting of frustrations with Medicare
Channel meaningful comments from constituents
9. CAC Evolution
Disseminate information to medical societies and specialties
Carrier has opened up information such as utilization, statistical data, program integrity, planned future changes
10. CMD Evolution CMD initially only reviewed complex claims
Some Fraud and Abuse examination
11. CMD Evolution Internal HCFA battle occurred between civil servants who felt that CMDs were a nuisance to be tolerated versus those who thought they could be an asset to HCFA. This battle continues at CMS today. (HCFA changed to CMS 2001)
2000 suggestion to do away with CMDs
12. CAC Description
Carrier Advisory Committee
13. Number of CACs One CAC per state except New England
New England has only a single CAC for four states (MA, VT, NH, MA)
Could become the norm under
new contracting rules and budgets
14. Purpose of CAC Three CACs per year (previously four)
Discussion of Local Medical Review Policies (LMRP) and Administrative Policies
Local Coverage Determinations (LCD) have replaced LMRPs
15. Purpose of CAC Formal mechanism for physicians to be informed of and participate in the development of LCDs in advisory capacity
Mechanism to discuss and improve administrative policies that are
within carrier discretion
16. Purpose of CAC Forum of information exchange between carriers and physicians
Not a forum for peer review, discussion of individual cases, or individual providers
Final implementation of policies rests with CMD in conjunction with Carrier and CMS policies
17. Role of CAC Members Disseminate proposed LCDs to colleagues in state and specialty societies to solicit comments
Disseminate information about Medicare program obtained at CAC meetings to state and specialty societies
18. Role of CAC Members Point out inconsistent or conflicting medical review policies
Point out items that conflict with community standard of practice
19. CAC Structure Each specialty and discipline shall have
at least one member
CMS defined specialties and disciplines
Non CAC members may attend as guests
20. CAC Structure Industry has attempted to infiltrate CACs
Pre CAC “Open meeting” is available to industry and non CAC members
Anyone may attend and comment at “Open Meeting”
21. CAC Structure Tenure at discretion of carriers
Co-Chairs are Medical Director and one other physician selected by committee
22. CAC Structure Carrier and CMS Participation is variable
Reports & Updates from-
CMS Regional Office representative
Medicare Part A Medical Director
Medicaid Medical Director
PRO/QIO representative
23. CAC Process Minimum of three meetings per year
Data relating to LCDs must be presented
No payment allowed for CAC participation
24. CAC Process Agenda and minutes will be sent to CMS
Discussion of LCDs is primary
defined CAC function
25. CAC Membership State medical and osteopathic societies
Managed care organizations
Chiropractic
26. CAC Membership Maxillofacial/Oral surgery
Optometry
Podiatry
27. CAC Membership Defined Medical Specialties---
Allergy
Anesthesia
Cardiology
Cardiovascular/Thoracic surgery
Dermatology
Emergency Medicine
28. CAC Membership Family Practice
Gastroenterology
Gerontology
General Surgery
Hematology
Internal Medicine
Infectious Disease
29. CAC Membership Medical Oncology
Nephrology
Neurology
Neurosurgery
Nuclear Medicine
Obstetrics/Gynecology
Ophthalmology
30. CAC Membership Orthopedic Surgery
Otolaryngology
Pain Medicine
Pathology
Pediatrics
Peripheral Vascular Surgery
Physical Medicine and Rehabilitation
31. CAC Membership Plastic and Reconstructive Surgery
Psychiatry
Pulmonary Medicine
Radiation Oncology
Radiology
Rheumatology
Urology
32. CAC Membership Clinical Laboratory
Beneficiary
Disabled Beneficiary
State Hospital Organization
33. CAC Membership PRO/QIO
Fiscal Intermediary Medical Director
Medicaid Medical Director
Medical Group Management Association
34. Other CAC Invitees Congressional Staff
CMS Regional Office Staff
Others at discretion of Co-Chairs
35. Membership List Availability CMS Regional Office
CMS Central Office
Provider Community (Single name or
entire list)
FOIA Requests
Other Groups (Drug and Device Manufacturers) are attempting to access
36. CAC Value to Practicing Physicians Provide input into LCDs
Be informed of changes by their CAC representatives
Any physician can request LCD reconsideration
Any physician can request new LCD
37. National Coverage Determination (NCD)
Anyone may request NCD by CMS
CMS scientific panel evaluates NCD request and makes decision to cover, decision not to cover, or leaves to discretion of local carriers
38. National Coverage Determination (NCD)
CACs and physicians have no input
into NCDs
NCDs generally take longer than
LCDs to implement
39. NCD
May be more NCDs (national) and less
LCDs (local)
If more NCDs the need for local CMDs in present form may decrease
40. LCD
LMRPs are both
Regulatory and Educational
LCDs are Regulatory only
41. LCD
LCDs require supplementary
educational articles
LCD can be challenged same as LMRP
Net effect of LMRP to LCD change
is minimal
42. Contracting New Medicare Administrative Contracts (MAC)
Combined Part A and Part B contracts
Completed by 2008
43. Contracting 15 Combined Part A & Part B contracts
Will there be a single CAC and single CMD for each jurisdiction?
Current New England model of single
Part B CMD and CAC for 4 States may become the norm?
44. Contracting
45. Contracting Jurisdiction 3 will be awarded in June 2006
(ND, SD, MT, WY, UT, AZ)
Jurisdiction 2 will be awarded June 2007
(AK. WA, OR, ID)
46. Contracting
47. The Future
What happens if CMDs and
CACs disappear?
Will all LCDs be replaced by NCDs?
48. MedPAC
The Medicare Payment Advisory Commission is an independent federal body established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program.
49. MedPAC
In addition to advising the Congress on payments to health plans participating in the Medicare+Choice and providers in Medicare's traditional fee-for-service program, MedPAC is also charged with analyzing access to care, quality of care, and other issues affecting Medicare.
50. AdvaMed
The Advanced Medical Technology Association represents more than 1,100 innovators and manufacturers of medical devices, diagnostic products and medical information systems.
51. AdvaMed
Members produce nearly 90 percent of the $71 billion health care technology products consumed annually in the United States, and nearly 50 percent of $169 billion purchased around the world annually.
52. NCD vs LCD
MedPAC calls for more NCD and elimination of local policies (LCD)
AdvaMed calls for keeping status quo
(prefer LCD to NCD)
53. NCD vs LCD Advantages and disadvantages either way
Mix of policies will probably persist although the mix between NCD and LCD may change
54. Questions
???