Medicare Local Medical Review Policies Tool Kit

The Medicare Local Medical Review Polices Tool Kit (LMRP) provides guidance to practicing psychologists interested in improving Medicare coverage for psychological services for older adults and other Medicare beneficiaries. American Psychological Association Committee on Aging & Office on Aging March 2003

Toolkit Home Part I: LMRP Basics Part II: Opportunities for Involvement Part III: The Tools Appendices

Introduction

The APA Committee on Aging (CONA) is often contacted by psychologists attempting to provide the best possible care for older adults and others, whose primary health insurance is Medicare. They express frustration in trying to understand the ins and outs of Medicare coverage for psychological and behavioral health services. They are baffled by the origin and rationale of Medicare coverage provisions and their geographic variability. For example, would the following provision concern you: "Psychotherapy is an effective adjunctive form of treatment for new psychiatric conditions, while other psychiatric illnesses primarily require treatment with medications."?

Recent changes in Medicare policies and procedures mandated by the Centers for Medicaid and Medicare Services (CMS), formerly the Health Care Financing Administration (HCFA), attempt to make the policy development process clearer and more accessible to Medicare providers.

These changes also create opportunities for concerned psychologists to provide input into the development of local medical review policies (LMRP) that determine coverage for services under Medicare. The importance of this opportunity cannot be overstated. It is a critical step in assuring the availability of appropriate and needed services for older adults and other Medicare beneficiaries.

In order to become involved, it is important for psychologists:

• to educate themselves about local policies and procedures
• to link with other like minded psychologists and organizations such as state-level psychological associations [link to SPAs]
• to gain access to the process resulting in important policy decisions
• to provide sensible, evidence-based input into decisions that dramatically affect patients' access to necessary care.

This LMRP Tool kit provides the information and necessary tools to make a difference. It is our hope that it enables more psychologists to become involved in the development of these policies that profoundly impact the availability of psychological and behavioral services for older Americans.

APA Committee on Aging (CONA) 2003

Acknowledgements

CONA would like to thank Leslie Fried, JD of the American Bar Association/ Alzheimer's Association Medicare Advocacy Project for bringing the LMRP issue to the forefront of their advocacy agenda. We applaud the Project's commitment to this issue and Ms. Fried's guidance in outlining critical components of this tool kit.

CONA expresses its appreciation to Eric Garfinkel, PhD of the New York Psychological Association, who provided the LMRP Project with his work product representing several years of accumulated effort in successfully working with the New York carrier to expand the availability of psychiatric and psychological services under Medicare.

CONA would also like to thank the Psychologists In Long Term Care organization for allowing us to include a sample of their correspondence in Part III of the tool kit.

Finally, CONA would like to acknowledge Susan Hurt, JD, PhD for her work as consultant to the APA Office on Aging and LMRP Project. Dr. Hurt's review and analysis of LMRPs nationwide and her role in the development of this tool kit are to be commended.

Goal/Content/Limitations of Toolkit

The goal of this tool kit is to help practicing psychologists provide important input into Medicare coverage for psychological services. Its focus is on Medicare Part B, Supplementary Medical Insurance. It provides basic information and tools to support your efforts to become involved in the development and revision of Local Medical Review Policies that determine coverage for psychological services under Medicare.

The tool kit contents are divided into three parts. Part I: LMRP Basics, provides a working knowledge of Medicare Local Medical Review Policies Ð definitions, typical policy provisions for psychological services and the primary parties. Part II: Opportunities for Involvement, suggests what you can do to become involved and describes the Process for LMRP development and revision, noting opportunities for psychologists to become involved in this policy development process. A Monitor on Psychology article highlighting the efforts of psychologists in NY to revise their LMRP is also included. Part III provides the tools to facilitate psychologist involvement in the LMRP process. Included are: examples of problematic language often appearing in draft LMRPs and revised language that more accurately reflects psychological research and practice; examples of recent positive changes in policy language; sample correspondence to the local insurance carrier; and, references for empirical studies which support the efficacy of a variety of psychological services.

There are two limitations of the Toolkit related to its scope. The Toolkit focuses on LMRPs and their development process. However, an LMRP is one part of a multi-layered set of policies and guidelines that control Medicare claims. The Center for Medicaid and Medicare Services (CMS), a division within the Department of Health and Human Services, has responsibility for administering the Medicare program. In turn, CMS contracts with various health care insurance agencies to manage the program locally.

This system of delegated responsibility, from Congress, to CMS, to private carriers, has resulted in a hierarchy of policies, rulings, and guidelines that control Medicare claims. For those interested in a more in-depth understanding of this hierarchy of laws, policies and guidelines that control Medicare claims, there are two sources of information:

To learn more about coverage provisions under Medicare, see the Code of Federal Regulations, Title 42, Public Health, Chapter IV at: http://lula.law.cornell.edu/cfr/index.php.

For a comprehensive database including the multiple sources of coverage provisions and controlling determinations, see newly created The Medicare Coverage Database http://cms.hhs.gov/coverage. It includes National Coverage Determinations, National Coverage Analyses and LMRPs.

For those interested in more general questions about Medicare, such as how to become a Medicare provider, see the APA Practice Directorate's Medicare Handbook http://www.apa.org/practice/medtoc.html.