APMA Addresses CAC Engagement and Cross Agency Issues with CMS | News | APMA
APMA Addresses CAC Engagement and Cross Agency Issues with CMS

March 13, 2023

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Updated March 11, 2024

On February 28, APMA moderated a meeting of the Contractor Advisory Committee (CAC) Engagement Coalition to evaluate CMS’ response to the coalition’s letter expressing our concerns with a July 2023 meeting between the coalition and representatives from CMS and Medicare Administrative Contractor (MAC) Medical Directors (the Workgroup). In that letter, the coalition expressed a desire to further engage with CMS to address these issues. After this most recent meeting, the coalition agreed to meet with CMS to highlight recent examples such as current problematic LCAs and to emphasize our concerns about CMS and the MACs’ inability to address these ongoing issues. The coalition also discussed efforts to grow the coalition, parallel AMA activities, and the likelihood of society support for legislative activity to provide additional clarification about the intent of the 21st Century Cures Act, which led CMS to reassess its approach to LCDs and LCAs, in many cases to the detriment of developing sound local coverage policies.

Previously on December 11, 2023, APMA, on behalf of the Contractor Advisory Committee (CAC) Engagement Coalition, submitted a letter to CMS expressing our concerns with a July 2023 meeting between the coalition and representatives from CMS and Medicare Administrative Contractor (MAC) Medical Directors (the Workgroup), and to express a desire to further engage with CMS to address these issues.

Prior to the July 2023 meeting, the coalition’s understanding, through regular communication with the liaison between the workgroup and our organizations, was that:

  • The MAC LCD workgroup was considering our concerns and recommendations;
  • The MAC LCD workgroup was making recommendations to the CMS Coverage and Analysis Group (CAG) on how and to what extent to address our concerns (estimated timeframe of May 2023); and
  • A follow-up meeting between the MAC LCD workgroup and our organizations would provide a debriefing of the workgroup’s recommendations and CAG’s responses.

As expressed in the letter, the July 2023 meeting failed to meet our expectations, as the MAC LCD workgroup participants and CAG representatives did not meaningfully acknowledge the concerns or recommendations we had raised. You can read the letter in its entirety at www.apma.org/comments.

On August 30, 2023, APMA met with members of its CAC Engagement Coalition to discuss updates from the coalition’s July meeting with representatives from CMS and Medicare Administrative Contractor (MAC) Medical Directors discussing the coalition’s recommendations to CMS and the MACs related to local coverage policy development. As part of the August meeting, the coalition discussed opportunities to broaden the coalition (including an updated white paper on the issues), narrowing the principles for policy development outlined in the group’s advocacy approach, and considerations for approaching CMS for further advocacy (including a proposed draft letter).

Previously, in July 2023, APMA and members of the coalition met with representatives from CMS and Medicare Administrative Contractor (MAC) Medical Directors. This meeting was designed to provide details on discussions between the MACs and CMS stemming from APMA and the coalition’s previous feedback on proposed improvements in the policy development process and CAC representative access. While the representatives from the MACs and CMS were not open to all of the suggestions from APMA and the coalition, APMA did make plans to continue working with the MAC CMD workgroup to address process improvement in multi-jurisdictional CAC subject matter expert selection and in review of developing policies.

In March 2023, APMA submitted to the MAC workgroup its Principles of Sound Local Coverage Policies and consensus answers to questions raised by CMS and the workgroup. APMA has been working with its CAC Engagement Coalition to reach these consensus positions.

Previously, on February 7, 2023, APMA met with the members of the CAC Engagement Coalition to review these materials and discuss consensus answers to questions raised by CMS and the MAC workgroup, which is investigating changes to the CAC feedback process brought about by 21st Century Cures Act. APMA plans to revise the group’s materials and share this information with the MAC workgroup and with CMS to help improve the process for developing LCDs and LCAs and contribute to more reasonable policies and better beneficiary care.

On January 9, 2023, APMA had previously gathered the CAC Engagement Coalition to gain consensus and set strategy for its upcoming meeting with the MAC workgroup. As part of this meeting, APMA shared questions that had been posed by the MAC workgroup as well as a draft document that APMA has created based on feedback by the coalition and stakeholders on Principles of Sound Local Coverage Policies. APMA’s involvement with the MAC workgroup came about through APMA’s leadership in the CAC process and LCD development as well as the strong working relationships between APMA’s CAC representatives and their contractor medical directors (CMDs).

Previously, on September 30, 2022, APMA and its CAC engagement coalition held a call with CMS in furtherance of their CAC engagement efforts to address cross-agency issues with CMS.

APMA and the coalition have experienced several challenges with the Local Coverage (LC) process in recent years and have brought those concerns to CMS’ Coverage and Analysis Group (CAG). The CAG has considered APMA’s concerns and is working to address many of them on an ongoing basis.

As previously reported in APMA Weekly Focus, the CAG has raised many of our concerns regarding CACs with the MAC medical directors, who have developed a working group to address concerns raised by this group, and with whom we are engaged to continue to work through several issues. However, other issues have hit roadblocks, so APMA requested this meeting with CMS to facilitate cross-agency engagement on these issues to help advance goals of transparency, burden reduction, and sound policy.

Specifically, APMA and the coalition again raised the following issues:

  • Lack of notice and comment regarding articles that determine coverage
  • Proper nomenclature and placement issues for “Articles” across CMS that do not address coverage
  • Performance metrics and additional accountability for MACs, including adhering to LCD timelines, new standards for CAC engagement, requirement to always include a draft LCA with the draft LCD for notice and comment
  • Need for an ombudsman to coordinate these issues

This meeting continues the efforts of APMA and the coalition to address lingering concerns regarding the Local Coverage Determination (LCDs) and Article (LCAs) review process, role of the CAC representatives, and other issues that APMA and our coalition have raised related to changes brought about by the 21st Century Cures Act.

Read more about APMA’s advocacy and the CAC process at www.apma.org/cacpiac and www.apma.org/medicare.


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