Recently, there have been some very troubling developments involving the Medicare Administrative Contractors – the MACs – that has ASN and other members of the kidney community highly concerned. The MACs, within a short window of time, have announced plans to limit reimbursement for dialysis that occurs more than three times per week exclusively to patients that meet specific acute conditions. The conditions have been outlined in a draft Local Coverage Determination (LCD). These draft LCDs propose that any claim linked to a Plan of Care that includes dialysis treatments occurring more than three per week—for any chronic condition or acute condition not included on the list—will be denied.
The ABCs of MACs
A. Medicare divides the country into 12 geographical jurisdictions
B. It contracts with private companies to serve as MACs to process Medicare Part A and Part B medical claims
C. MACs make Local Coverage Determinations (LCDs), but only Medicare can make national policy through the rulemaking process governed by the Administrative Procedures Act1
D. MACs pay $386 billion in Medicare benefits annually
E. MACs process more than 1.2 billion Medicare FFS claims annually, 218 million Part A claims and more than 1 billion Part B claims2
ASN has been working with a wide range of kidney groups and coalitions to advocate for the rejection of the LCDs. ASN objects to the proposed policy change on the grounds that the change:
Violates the physician-patient relationship
Discourages medically-justified individualized care
Does not recognize both acute and chronic conditions and care needs
Places undue administrative burden on physicians
Violates current CMS policy
ASN is asking readers to reach out to their respective MACs in writing to register their objection to the proposed LCDs. A sample letter and instructions for contacting your MAC are on the ASN website.
ASN has highlighted numerous clinical examples to support its points as well as policy objections. For example, KDOQI Clinical Practice Guideline for Hemodialysis Adequacy: 2015 Update (recommendation 4.1.1) instructs physicians on an individual, patient-by-patient basis to “Consider additional hemodialysis sessions or longer hemodialysis treatment times for patients with large weight gains, high ultrafiltration rates, poorly controlled blood pressure, difficulty achieving dry weight, or poor metabolic control (such as hyperphosphatemia, metabolic acidosis, and/or hyperkalemia).” Substantial evidence suggests clinical benefits associated with more frequent hemodialysis.
ASN maintains that the proposed LCDs exceed the bounds of the MACs’ authority in trying to restrict what conditions can be covered for more than thrice-weekly dialysis with medical justification. As CMS rules and guidance have made clear, the decision regarding medical justification must be made on an individual patient basis. That makes the proposed LCDs contrary to current CMS policy.