Fair OT Coverage Under Medicare: LCDs FAQ

Regional Medicare Local Coverage Determinations (LCDs) are undergoing some changes. Under the Medicare Program, Medicare contracts with regional corporate entities that process and pay claims for services provided in their regions which may range from one state to multiple states to parts of states. These entities, usually insurance companies, have in the past been called “carriers” or “fiscal intermediaries” but due to recent legislative changes are moving to be called Medicare Administrative Contractors (MACs). This article presents key issues about LCD changes already underway, and opportunities for advocacy.

What is an LCD?

LCDs are coverage and payment policies that have been used by current carriers and fiscal intermediaries but will also be used in the regions covered by the new MACs to interpret national Medicare policy issued by the Centers for Medicare and Medicaid Services (CMS). LCD coverage policies may be based on discipline (e.g., an LCD might be titled “occupational therapy” or “physical medicine and rehabilitation”) or type of service (e.g., wound care services; dysphagia services and so forth).

What is Changing?

The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) enabled CMS to make significant changes to the Medicare fee-for-service program’s administrative structure. The key feature is that the MACs will gradually be identified over the next several years to replace the old carriers and fiscal intermediaries. Under the law’s provision for Medicare Contracting Reform, CMS will integrate the administration of Medicare Parts A and B into one regional entity-a MAC. All Part A and B fee-for-service claims will be processed through these new entities. As part of the reform, CMS is conducting open competitions to replace contractors but it will take time. Affected regions are being phased in from 2005-2011.

What is Affecting Occupational Therapy Now?

The MACs are currently being selected and as part of the reform process, LCDs are under review. As MAC contracts are awarded to local Medicare contractors, these contractors are re-examining existing LCDs that govern Physical Medicine and Rehabilitation policies in their coverage region and are consolidating and revising the LCDs, typically through a stakeholder notice and comment process.

What Should Occupational Therapy Practitioners Do About the Changes?

The changing contracting process is one reason for the recent explosion of open LCDs and requests from new MACs for therapists to provide comments on an LCD. LCDs are required to allow for some public comment. It is imperative that practitioners follow the changes in the process and entities that affect their Medicare billing by watching the Web sites of current and new entities.

While some LCDs recognize the full scope of occupational therapy practice, LCDs frequently present inappropriate or erroneous information on the occupational therapy scope of practice and that of other therapy disciplines. Further, these inappropriate LCDs may lead to AOTA members receiving widespread Medicare denials of claims for services that occupational therapists are educated and licensed to provide. There have always been efforts made by therapists and sometimes state associations to affect and change LCDs; AOTA also weighs in with comments on many LCDs. With the many changes now happening, it is important that all in the field watch what entities are doing to protect occupational therapy practice, payment, and scope of practice. The best source of information is the Web site of your current fiscal intermediary or contractor. Changes to MACs will be posted there.

What Materials Are Available to Help Me Be an Advocate on LCDs?

AOTA wants to provide members with the following tools and resources to respond to requests for comments on LCDs:

• LCD Advocacy Packet: This packet provides the materials and resources necessary to enable state associations and individual practitioners to monitor and advocate for OT services under Medicare, critical fact sheets, AOTA official documents, and sample LCD comment letters are included.

• Medicare Benefit Policy Manual – Presents frequently used citations. (See Chapter 15)

Article from www. AOTA.org