How Medicare's Local Carrier Determinations Affect You

The Private Medical Practice Academy

You’re a Medicare provider. And you know that the Centers for Medicare and Medicaid Services (CMS) runs Medicare. But did you know that CMS is just the umbrella organization? The actual administration is done by a Medicare Administrative Contractor (MAC.)

What is a MAC?
A MAC is a private health care insurer that’s been awarded a geographic jurisdiction to process claims for Medicare Fee-For-Service beneficiaries.

CMS relies on the network of MACs to serve as the primary operational contact between the Medicare Fee-For-Services program and providers enrolled in the program. Some of the activities the MACs include:

• Processing claims, enrolling providers, handling 1st stage appeals redetermination requests, responding to provider inquiries, educating providers about Medicare billing requirements, reviewing medical records for selected claims and establishing local coverage determinations

One of the functions of each MAC is to establish local coverage determinations (LCD.) An LCD is a determination of whether a particular item or service is going to be covered on a contractor–wide basis.

Before an LCD can be put in place, there's a whole process:

• The Proposed LCD describes the MAC’s proposed determination regarding coverage, non-coverage or limited coverage for a particular item or service. The public announcement begins with the date the proposed LCD is published on the Medicare Coverage Database.
• After the proposed LCD is published, the MAC has to provide a minimum of 45 calendar days for public comment.
• The MAC has to establish a Contractor Advisory Committee to discuss the quality of evidence used to make a determination. You can volunteer to be part of the CAC.
• The MAC holds open meetings to discuss the review of the evidence and the rationale for the proposed LCD.
• Once these steps are completed, the final LCD and the response to comment is published. This marks the beginning of the required notice period of a minimum 45 calendar days before the LCD can take effect.

There is an LCD reconsideration process. As a physician you can request a revision to an LCD—either in its entirety or any provision.

An LCD can definitely throw a wrench into your revenue cycle management if it takes you by surprise. It’s imperative that your billing folks keep you abreast of any new LCDs or changes to an existing one.

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