December 2020 updates
STARK LAW REVISION: The law prohibiting Medicare self-referral was passed in 1989. As CMS has begun to realize the role of value-based payments, they became keenly aware certain arrangements that were previously prohibited could lead to improved quality outcomes, improved health system efficiencies, and lower costs. Details of this new role will become increasingly clear over the next few weeks but it is hopeful that demonstrating quality, cost-effective care will finally be rewarded as opposed to punished.
As many of you are aware, First Coast Service Options, which is the Medicare carrier for Florida, has joined with Novitas under a single parent company. It is expected that they will have similar if not identical coverage policies in the near future. New LCDs for FFR-CT and for non-invasive testing for stable ischemic heart disease are being developed. Although they’re developed by regional Medicare carriers, it is assumed that the chosen LCD will eventually serve as an NCD applicable to our patients with standard fee for service Medicare. A final coverage policy for FFR CT is being developed. The American College of Cardiology has recently submitted suggestions for expanding coverage.
Novitas is proposing an LCD on testing for stable ischemic heart disease. Cardiac PET is covered for perfusion but there is no specific mention of myocardial blood flow. FDG imaging for cardiac sarcoidosis is covered only if the patients are unable to carry out cardiac MRI. Serial testing in a stable asymptomatic patient is not considered appropriate for coverage. All stress modalities are considered equal. Therefore, it should clear the way for a clinician to choose the best test is for his/her patient. My concern is this may lead to test substitution. Again, our national ACC is very much involved in this.
First Coast is now requiring dual diagnosis for cardiac stress test time. This is leading to significant denials. Although most claims are paid on first or second appeal, it can take up to 120 days or more for payment. Obviously, this is unacceptable. National and state chapters and subspecialty organizations are all working on this together. For more information please review: https://medicare.fcso.com/Cardiology/0469513.asp.
United Health Care appears to be encouraging the use of coronary CTA and FFR-CT preferentially functional imaging (MPI, stress echo, stress CMR) in patients who are loaded intermediate risk they apply that most functional imaging will no longer be required in the future. There is significant industry support behind this initiative including an industry supported white paper that was published in JACC. The FCACC is working with national ACC to ensure the patient receives the right test at the right time when the physician completes the appropriate use criterion.
Humana has declared cardiac PET-CT an experimental procedure and is refusing coverage. All dedicated standalone PET cameras require CT attenuation and thus must carry out a CT scan for attenuation correction. This is clearly different from a hybrid diagnostic CT. Florida ACC is working with ASNC, SNMMI and national ACC in an attempt to resolve this critical reimbursement issue.
On the good news front BCBS of Florida is covering coronary CTA for intermediate preclinical risk ages 40-75. For details consult the following: http://mcgs.bcbsfl.com/MCG?activity=openSearchedDocMcg&imgId=75S7UABPY9FVM4CMREP
Local Coverage Determinations - HOW THE FL CHAPTER ACC GETS INVOLVED TO GET PATIENTS THE RIGHT CARE AT THE RIGHT TIME
Medicare uses a variety of mechanisms to set policies for coverage of services. At the national level, the Centers for Medicare and Medicaid Services (CMS) may issue a National Coverage Determination (NCD). Medicare administrative contractors (MAC) may issue Local Coverage Determinations (LCDs) or may choose to cover services or therapies on a case-by-case basis. If an NCD or LCD does not exist, it does not simply mean that Medicare will not pay for the service.
When national coverage has not been specified in NCD, MACs may choose to provide coverage for a service through an LCD. An LCD may be written in a manner that provides broad coverage, coverage with certain restrictions, or non-coverage. MACs develop LCDs through a process that is less formal than that used to develop an NCD. That process includes expert feedback from designated physician representatives. In Florida these include our CAC Representatives listed about who attend three formal meetings per year and consult with our carrier, First Coast Service Options.
Additional Tools for Practices
Heart House has developed a network of CAC representatives from across the nation that meet as a group to review trends and analyze issues. The chair of the Third Party Reimbursement Committee is active at the national level through meetings and constant communication with colleagues.
National ACC has a web portal dedicated to practice issues. See this link for in-depth issues."Do Your PART" to Improve the Prior Authorization Process