Medicare Local Medical Review Policies Tool Kit

Part II: Opportunities for Involvement • What You Can Do To Get Involved • Top 10 Reasons You Should Get To Know Your Carrier Medical Director Now • How to Find your Local Carrier Medical Director and Carrier Advisory Committee • LMRP Formulation and Revision: Opportunities for Involvement • New York Psychologists Success in Revising their LMRP

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

Part II: Opportunities for Involvement

What YOU can do to get involved

1. Although individual psychologists can raise the awareness of the local carrier in areas of import to psychology, the CAC process has built-in respect for efforts and presentations by professional societies, so that it may be a good idea for the initial and ongoing communications to demonstrate support of an organized group.
2. Find out what activities are already underway at your State psychological association. Is there already a committee in place addressing Medicare or insurance issues?
3. Work with a local committee, or establish a Medicare Committee of like-minded providers of psychological services to:
1. Systematically review draft policies on the LMRP website (www.draftlmrp.net) to track proposed changes to policy provisions regarding psychological services
2. Contact your local CMD and make your presence known
3. Take advantage of all open meetings for comments on draft LMRP language
4. Submit written comments via letter or e-mail on draft LMRPs
5. Organize with other interested providers to request changes to undesirable policy language in existing LMRPs
6. Offer your services or that of your committee to receive and review all policy changes regarding psychological services for the purpose of offering helpful input
7. Request an invitation to CAC meetings when policy provisions regarding psychological services are on the agenda.
4. Read on to learn more about the Process for LMRP development and revision, and corresponding points of opportunity for involvement.

Top 10 Reasons You Should Get to Know Your Carrier Medical Director (CMD) NOW:

1. 10. CMS has recently promulgated notice and comment periods for all new and revised LMRPs, giving health care practitioners and their representative societies better access to the LMRP process.
2. 9. CMS has recently required that all LMRPs be reviewed annually, increasing opportunities for input from interested parties.
3. 8. CMS has recently clarified national policy on coverage for dementia, prohibiting local carriers from automatically denying claims.
4. 7. CMS has recently provided that carriers must consider all LMRP reconsideration requests from providers doing business in a carrier's jurisdiction.
5. 6. Psychologists are not currently included as required representatives on CAC's, so that additional contacts are necessary to remain visible in the LMRP development process.
6. 5. CMDs are physicians representing numerous medical fields and may or may not be informed about the unique contributions of psychologists to beneficiaries' mental health.
7. 4. The CMD is required to consider scientific evidence presented by psychologists.
8. 3. The strength of the scientific basis for state-of-the-art psychological services should be made known to parties responsible for important decisions about patients' access to services.
9. 2. Psychologists in New York developed relationships with their CMD over several years before effecting beneficial policy changes.
10. 1. The CMD is primarily responsible for developing new LMRP language.

How to find your local CMD and CAC

Carrier Medical Directors are listed by name in the Carrier Directory section of the main LMRP website (www.lmrp.net; Directory; Part B). This should be a good starting point for contact information and meeting dates for your local Carrier Advisory Committee.

LMRP Formulation and Revision: Opportunities for Involvement

Carriers develop and revise LMRPs for a variety of reasons at a variety of times. For a listing of circumstances when a carrier must develop or revise an LMRP, when a carrier may develop or revise an LMRP, and when an existing LMRP must be reviewed, [click here] Ð Editor note: taken to Appendices.

The objective of this tool kit is to encourage psychologists to remain vigilant and ready to seize available opportunities to assure proposed provisions are reflective of psychological research and practice. Therefore, this section will describe new developments that allow increased opportunities for input by psychologists and types of information that can be submitted. The last section segment highlights successful efforts by New York psychologists to revise their LMRP.

Recently Promulgated Requirements for Development and Revision of LMRPs

CMS recently promulgated requirements that carriers post their draft LMRP's and dates of meetings, including provision of a forum for discussion of coverage terms, on the internet (Program Memorandum, Transmittal AB-00-116, dated November 24, 2000). CMS has also recently provided that carriers must consider all LMRP reconsideration requests from providers doing business in a carrier's jurisdiction (Rev. 34, 11-22-02, Medicare Program Integrity Manual, Chapter 13). Specifically,

• Carriers must provide open meetings for the purpose of discussion of draft LMRPs and must allow interested parties to submit scientific, evidence-based information, professional consensus opinions, or any other relevant information
• If time or space are insufficient for all information to be presented in open meeting, then comments provided to the CMD in writing, including by e-mail, must also be given full and equal consideration.
• A draft LMRP must be posted on the carrier's web site, with information on the start and stop date of the comment period and both email and postal addresses for comments. The comment period must be a minimum of 45 days. The web site must also contain an "LMRP status page," setting forth the development, comment and finalization timelines and available comment mechanisms.
• The carrier's web site must provide a summary of comments received concerning the draft LMRP with the carrier's response. The comment/response document needs to be posted on the web for 3-6 months.
• After all comments have been considered and all revisions made as needed, the carrier must provide a minimum notice period of 45 calendar days on the final LMRP.

Who is Expected to Comment?

The carrier must solicit comments and recommendations on the draft LMRP from at least the following sources:

• Appropriate groups of health professionals and provider organizations that may be affected by the LMRP;
• Representatives of specialty societies;
• Other intermediaries/carriers;
• Quality Improvement Organizations within the region;
• Other Carrier Medical Directors within the region;
• General public;
• Carriers should make an effort to ensure that providers with a history of billing for the service are informed of the proposed LMRP and have an opportunity to comment.

What information is used to develop LMRPs?

• In general, all policies providing or limiting coverage under Medicare are supposed to be based on the strongest evidence available.
• The best evidence for policy language is published authoritative evidence derived from definitive randomized clinical trials or other definitive studies.
• If such evidence is not found for the coverage question at issue, then the policy language should reflect general acceptance by the medical community (standard of practice), as supported by sound medical evidence. Sound medical evidence may be derived from scientific data or research studies published in peer-reviewed medical journals, consensus of expert medical opinion, such as recognized authorities in the field, or medical opinion derived from consultations with medical associations or other health care experts.

Where does the carrier start in developing new LMRP language?

• First, the carrier determines if a policy which addresses the issue is already in existence. The carrier may contact other carriers directly, may use the LMRP website, or may use other sources of information.
• If another policy exists, the carrier will likely adopt or adapt the existing language if at all possible.
• If another policy covering the same issue is not found, then the carrier may develop original policy language.

New York Psychologists Success In Revising their LMRP

Recent federal mandates allow psychologists and the general public to comment on Medicare policies. Monitor on Psychology article, January 2002

BY DEBORAH SMITH
Monitor staff

A new public comment process could expand the type and frequency of psychological and medical services that Medicare will cover for older adults and people with disabilities.

The comment process, mandated by the U.S. Department of Health and Human Services' Centers for Medicare and Medicaid Services (CMS), requires all Medicare carriers to allow the public to review and comment on the guidelines they use to determine whether medical and psychological services are covered. That new comment period opens the door for psychologists to explain why behavioral services are an important part of many Medicare recipients' care.

"This is a wonderful opportunity for psychologists to have a voice in Medicare policy," says Forrest Scogin, PhD, a member of APA's Committee on Aging (CONA), which is tracking the progress of the new public comment process and its impact on local policies. "Many patients rely heavily on Medicare for access to services, and we know that there are psychological services that can be beneficial for [them]. Unless we advocate for their inclusion, we lose out on opportunities to provide services, and the patients are deprived of the use of those services."

The public comment process applies to the thousands of guidelines that individual Medicare carriers establish to determine reimbursement for services, ranging from psychological assessments to physical therapy to cataract surgery. These guidelines, called Local Medical Review Policies (LMRPs), vary by state. During the review period, the carrier is now required to post the draft LMRP on a CMS-run Web site (www.draftlmrp.net).

CONA members say that if mental health professionals take advantage of the new public comment process, they could make a substantial difference by lobbying for needed psychological services for older adults and their caregivers.

The new rules not only allow psychologists to educate their Medicare carriers about the importance of these services but also to educate themselves about the LMRP process so that they can properly bill and be reimbursed by Medicare, says Diane Pedulla, JD, director of regulatory affairs in APA's Practice Directorate.

"The LMRP may contain nuances that are critical to accurate billing for services," Pedulla explains. "The LMRPs typically provide more information than is listed in the American Medical Association's billing codes, such as requiring extra documentation."

Psychologists in New York are already taking advantage of the new federal rules by working with their state's Medicare Carrier Advisory Committee (CAC), the group of physicians and other stakeholders that drafts LMRPs and accepts the public's comments.

Last year, for example, the New York State Psychological Association (NYSPA) and its members used their long-standing relationship with the state's CAC to help redraft the state's LMRP on mental health coverage to recognize the importance of mental health services for Medicare recipients, including coverage for those in the early stages of dementia or Alzheimer's disease and appropriate treatment for individuals with serious mental illness.

Initially, the draft policy stipulated that psychological services had to be prescribed and supervised by a psychiatrist, required that patients with depression take medication in order to have psychotherapy, and recommended extremely limited treatment sessions for major psychological disorders.

"We had negotiated our previous LMRP very successfully, so it was extremely unsettling when we received a potentially devastating new policy draft in 2000," explains NYSPA legislative chair Eric Garfinkel, PhD. He and Frank Goldberg, PhD, led a cadre of psychologists concerned about the possible effect of these regulations. They compiled psychological research to show why mental health services are important for older adults and people with disabilities, and wrote a suggested revision of the LMRP.

"We gave them a carefully constructed and comprehensive alternative draft and a thick binder full of supporting documentation," Garfinkel says, noting that the carrier was probably receptive to their suggestions because NYSPA psychologists have been working alongside the state's CAC for years. Garfinkel, Goldberg and their colleagues have attended almost every LMRP meeting, not just those that address mental health concerns.

"Demonstrating our commitment and respect for the process," says Garfinkel, not only helped to establish a strong working relationship, but also allowed them to learn more about how the carrier does business. "You have to help the carrier do its job," he adds, explaining that it's important to understand the forces that can influence the carrier's decisions. "Don't complain about the policy--help them write a new one."

To help others emulate New York's success, CONA and APA's Office on Aging are developing a tool kit that will include information about LMRPs, how CAC meetings work, literature citations for the importance of psychological services for older adults--especially for dementia and Alzheimer's patients--and examples of some successful advocacy efforts.