Senate Renews Efforts to Reform LCD Processes

Efforts to improve the local coverage determination process have been renewed with the introduction of the Local Coverage Determination Clarification Act of 2017. The proposed bill is the result of bipartisan efforts—sponsored by two Democrats and four Republican senators—and revises the process by which Medicare contractors set local policies for Medicare coverage of physician services, creating more transparency and imposing additional procedural requirements.

“The Senate bill would ensure that coverage decisions are made by qualified independent health experts through a transparent process that is based on sound medical evidence,” explained College of American Pathologists President Richard C. Friedberg, MD, PhD, FCAP, in a statement praising the legislation and thanking its sponsors for their efforts to fix a “broken” LCD process.

An act by the same name was also introduced last year but didn’t make it through Congress. Similar reforms are included in this year’s proposed legislation:

• Open, public meetings for the Medicare Administrative Contractor’s (MAC) Carrier Advisory Committee to allow input from experts, with minutes of the meetings posted online for public inspection.

• Opportunity for public comments regarding draft LCDs—at least a 30-day comment period required.

• Disclosure online of the evidence and rationale underlying local policy decisions to deny coverage. “If this information is not provided until the final LCD, it hinders meaningful stakeholder exchange and makes the MAC’s decision to deny coverage almost a foregone conclusion,” the College of American Pathologists said in a statement applauding the proposed bill.

• Procedural requirements for the reconsideration and appeal processes that include establishing an ombudsman.

• Preventing a single MAC from making express or de facto national determinations by requiring MACs that want to adopt LCDs from a different geographic region to first independently evaluate the evidence supporting the LCD and make its own determination. “The CAP has witnessed the carbon copy adoption of MAC LCDs by other MACs without the benefit of meaningful solicitation or independent assessment of comments and concerns from the public or medical community of the adopting MAC,” the CAP said in a statement. “The policy then can become of such geographic magnitude it approaches becoming a NCD in practical terms without having followed more rigorous requirements.”