The CAP Applauds The Introduction Of HR 5721 To Reform Medicare’s LCD Process

Contact: Charles Fiegl
Phone: 202-354-7134
E-mail: MEDIA@CAP.ORG

Washington, DC —The College of American Pathologists (CAP) applauds the introduction of House legislation to improve transparency and accountability when Medicare contractors set local coverage determination (LCD) policies to ensure physician medical judgment and beneficiary access to medically necessary care are not impeded.

The CAP shares the goals found in the Local Coverage Determination Clarification Act introduced by Reps. Lynn Jenkins (R-KS) and Ron Kind (D-WI). The bill seeks to ensure Medicare LCDs are made by qualified health experts through a transparent process based on sound medical and scientific evidence supported by medicine. Changes in the bill include open meetings, upfront disclosure of medical evidence and rationale, new options for reconsideration and appeal, and prohibiting the use of LCDs as a backdoor to national coverage determinations.

From a pathologist's perspective, a faulty LCD could replace physician judgment with arbitrary and unsubstantiated rules. This would hinder the pathologist's ability to render an accurate diagnosis and potentially deny patients treatments from which they may benefit. In addition, they can interfere with the practice of pathology and do not serve the public good nor ensure Medicare beneficiaries receive appropriate access to medically necessary diagnostic services.

"The patients and the physicians who treat them stand to benefit from changes prescribed by this legislation to reform the LCD process," said CAP President Richard C. Friedberg, MD, PhD, FCAP. "When Medicare contractor decisions are made without the benefit of transparency to the public, an LCD can interfere with our medical judgment and adversely affect patient access to medically necessary care. Introducing common sense measures found in the reform bill will improve transparency and accountability, and provide a meaningful appeals process for challenging flawed coverage decisions. We applaud and commend Reps. Jenkins and Kind for their work on this issue and for introducing these much needed reforms."

The CAP supports HR 5721. In particular, the following principles contained in the legislation to improve the LCD process:

• Open Meetings: Medicare Administrative Contractor’s (MAC) Carrier Advisory Committee (CAC) meetings must be open, public, and on the record. Minutes should be posted to the MAC's website for public inspection. The gravity of limiting or precluding coverage for both beneficiaries and practitioners heightens the need for transparency where meetings are currently closed.
• Upfront Disclosure: MACs should include at the outset a description of the evidence considered when drafting an LCD as well as the rationale they rely on 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.
• Meaningful Reconsideration and Options for Appeal: A meaningful LCD reconsideration process gives Medicare providers and suppliers the opportunity to have a secondary review by a qualified disinterested party. Under current Centers for Medicare & Medicaid Services (CMS) rules, MAC LCDs are essentially unreviewable for providers and suppliers without new evidence submitted to the very MAC that issued the LCD.
• Stopping the use of LCDs as a backdoor to National Coverage Determinations (NCDs): Prohibit the CMS from appointing a single MAC, either expressly or in practice, from making determinations to be used on a nationwide basis in a given specialty. 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 policy then can become of such geographic magnitude it approaches becoming a NCD in practical terms without having followed more rigorous requirements.

About the College of American Pathologists

As the leading organization with more than 18,000 board-certified pathologists, the College of American Pathologists (CAP) serves patients, pathologists, and the public by fostering and advocating excellence in the practice of pathology and laboratory medicine worldwide. The CAP's Laboratory Improvement Programs, initiated 65 years ago, currently has customers in more than 100 countries, accrediting 7,800 laboratories and providing proficiency testing to 20,000 laboratories worldwide. Find more information about the CAP at CAP.ORG. Follow CAP on Twitter at @PATHOLOGISTS.