Medicare Compliance & Reimbursement

Beginning Oct. 27, Medicare national coverage determinations will follow newly defined tracks, with established deadlines, under a revised process announced in the Sept. 26 Federal Register.

An NCD "is a national policy statement granting, limiting, or excluding Medicare coverage for a specific medical item or service." NCDs are binding on Medicare, its bill-paying contractors, Medicare health plans, and generally anyone who pays bills for or provides coverage for beneficiaries' care.

One of two tracks for obtaining a new NCD is the so-called BIPA appeal, set up by Congress in the Benefits Improvement and Protection Act of 2000.

Bipartisan members of the House Ways and Means Committee - who wrote the provision - have hounded the Centers for Medicare & Medicaid Services repeatedly to establish a regulatory process to ensure that statutory deadlines for BIPA appeals will be met. And under the new policy, CMS is pledging to hew as strictly as it can to the 90-day deadline set forth in the law.

This streamlined BIPA appeal is available only to Medicare beneficiaries - dubbed "aggrieved parties" in the legislation - who are in need of but have been unable to receive a given item or service for which no national determination to cover or not to cover has ever been issued.

CMS says that once it receives and accepts a complete, written request from an aggrieved beneficiary, the agency plans to issue a decision memorandum and an NCD to its contractors by the BIPA deadline - no later than the end of a 90-day period. "In cases where we are not able to complete our review within this 90-day timeframe, the law requires that we issue a notice that includes an identification of the remaining steps in the review process and a deadline by which we will complete that review," says the Register notice.

A second track for obtaining a new NCD is available to anyone - including beneficiaries, manufacturers, providers, and suppliers - "who identifies an item or service as a potential benefit (or to prevent potential harm) to the Medicare population," says the Register notice. This track will use a "more collaborative" decision-making process than the deadline-driven BIPA appeal, and therefore will take "a more flexible approach to the 90-day clock."

For appeals on this track, "requesters and other interested parties will be able to provide additional information, clarify issues, and engage in dialogue as questions arise," says the notice.

CMS also has clarified that it no longer intends to develop a major new rule for coverage determination, as the agency announced in May 2000 that it intended to do. The 2000 notice of intent was highly controversial because it proposed a coverage-determination process that would have compared both the care-effectiveness and cost of some new technologies to technologies already covered by Medicare.