The Current Status of Local Medicare Payment Policy: How Specialty Societies Can Influence Local Coverage Determinations

The Medicare Fee-for-Service Program is in the midst of numerous administrative and regulatory changes that may affect the way local Medicare payment policy is implemented. These changes involve redefining the contractors' jurisdictions, competitive bidding for the contractor selection process, combining the administration of Part A and Part B services, and error rate auditing. In addition, the roles of the Contractor Medical Directors and Contractor Advisory Committees are yet to be defined, and the future of the existing advisory process, while currently unchanged, remains uncertain. Most likely, the majority of coverage decisions will continue to be made at the local level; however, the Centers for Medicare & Medicaid Services (CMS) has begun to increase its use of Technology Assessments and National Coverage Determinations for new technology and has developed a new payment category for coverage of new technology: Coverage with Evidence Development. Specialty societies continue to have the ability to exert influence on the coverage process. The American College of Radiology (ACR) monitors the activity of the local contractors and assists local physicians through the ACR Carrier Advisory Committee Network. The ACR has used a combination of clinical and economic experts to develop model Local Coverage Determinations for use by the local contractors, and some of these model policies have been developed in conjunction with other specialty societies, which bolsters their effectiveness. The changing administrative environment presents challenges and opportunities for specialty societies to influence local CMS payment policy.