First Quarter 2008 - Issues in Hematology - ION Solutions

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eimbursement watch1423613215815124101171Figure1. Medicare Part A/B MAC Jurisdictions9oncologistics volume 7, issue 1 - spring 2008 26LEGACY CONTRACTORS, FISCAL INTERMEDIARIES,AND CARRIERSPart A/B MACs will now be the sole claims processorsfor services rendered in both physician offi ces andhospitals, duties previously processed separately bycarriers and fi scal intermediaries. The impact of MACreform on Medicare providers and benefi ciaries maydepend on whether or not their new MAC is alreadyan existing Medicare legacy contractor in their region.For example, providers in the J4 region, which includesthe states of Colorado, New Mexico, Oklahoma, andTexas, are transitioning to TrailBlazer Health Enterprises,LLC (TrailBlazer), and may experience fewer changessince TrailBlazer was a legacy contractor for these J4states. The company previously operated as a Part Bcarrier for Delaware, the District of Columbia, Maryland,Texas, and Virginia, and as a fi scal intermediary inColorado, New Mexico, and Texas. Outgoing legacycontractors transitioning their current responsibilitiesto TrailBlazer include:> Group Health Service of Oklahoma> Part A Fiscal Intermediary (OK)> Noridian Administrative Services> Part B Carrier (CO)> Pinnacle Business Solutions> Part B Carrier (NM, OK)Conversely, Wisconsin Physician Service (WPS) did notoperate as a Medicare contractor in the J5 states of Iowa,Nebraska, Kansas, and Missouri prior to its award onSeptember 5, 2007, as a MAC in that jurisdiction. Itsnew status as a MAC creates an opportunity for WPS toeducate providers on unfamiliar processes related toclaims submission, redeterminations or appeals, as wellas the applicability of new local coverage determinations(LCDs). Still, regardless of whether a region’s MAC isa legacy Medicare contractor or not, providers will haveto juggle potential changes in coverage policies andoperational requirements.WHAT TO WATCH FORStaying on top of MAC-related developments will beimportant as each jurisdiction starts transition activities.Being aware of jurisdiction-specifi c timelines related tolocal contractor transition dates and policy changes willhelp ensure appropriate and timely claims payment. Eachstate within a specifi c jurisdiction may have a differenttransition date (also referred to as a “cutover date”), which
oncologistics reimbursement watchcan include separate transition timelines for the Part Aand Part B workload (claims processing responsibilitiestransferred from a legacy carrier or fi scal intermediary to aMAC). Providers will want to track the transition from theircurrent, legacy contractor to a new MAC for importantinformation such as:> Deadlines to submit electronic fi le transferagreements to the new MAC> Cutoff dates for the submission of electronic andpaper claims, redetermination requests, and auditsto the outgoing contractor> Reviewing resources, such as transition checklistsand communiqués available on the new MAC’s Website section designated for new MAC providers> Watching for signifi cant education andoutreach initiatives> Researching Frequently Asked Questions (FAQs)as they are posted by other providers> Obtaining and saving claims addresses, phoneand fax numbers, and interactive voice responsesystem processes> Last date the outgoing contractor will make claimspayments and keep their interactive voice responsesystem open> Last date for cost reports and cost report appeals> System Dark Day (cut off date for all services fromthe outgoing contractor)> First day the MAC will accept electronic orpaper claims> Date when the MAC will begin the claimspayment cycle> Date when the MAC will start offering customerservice for providersPhysician practices can stay involved with and aware ofupcoming details that may affect claim processing by:> Visiting their MAC’s Web site and bookmarkingimportant information> Joining listservs and trainings to stay up-to-date onimportant cutover dates and details> Dialing into MAC teleconferences to ask questionsand to voice concerns> Staying abreast of dates for MAC teleconferences aspublicized through listservs, provider education, andevent calendars, or on the MAC’s Web site> Reviewing and submitting comments on newjurisdiction-specifi c LCDs to have a voice in thepolicy revision processREMAKING LOCAL COVERAGE POLICIESThe consolidation of local policies, also known as LCDs,by newly awarded MACs is among the most prominentand important changes associated with MAC reform.Different MACs may take different approaches inconsolidating policies. In most cases, CMS instructsMACs to select the “least restrictive” LCD on a singletopic. However, in practice, contractors have exercisedsignifi cant latitude when consolidating existingcoverage policies within a jurisdiction. Contractorsmay vary in their interpretation of what is considereda “least restrictive policy.” MACs may differ in howto treat legacy contractors that have not published apolicy on a particular topic, how to apply standards of“clinical appropriateness,” and whether to implement ajurisdiction-wide policy or restrict a policy toa certain workload (i.e., Part A or Part B).The recent policy consolidation activities in J4 andJ5 give some insight into how this process may playout in other parts of the country. Both the J4 and J5MACs have chosen different approaches to their policyconsolidation process. WPS and TrailBlazer offereddetailed explanations as to how they consolidated LCDsin their jurisdictions. Based on our experience examiningsome of the new MAC LCDs, we have noted:> Depending upon the product or drug class, WPScollected sections from several LCDs on a topicarea from the legacy contractors and pieced themtogether to create a “clinically appropriate” LCD.WPS has decided not to always implement an LCDoncologistics 27
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First Quarter 2008 - Issues in Hematology - ION Solutions

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