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AAOS Now

Published 9/1/2014
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Elizabeth Fassbender

MACs, CACs, and Orthopaedics

Ensuring orthopaedic input on local coverage determinations

Medicare Administrative Contractors (MACs) are multistate, regional contractors that process Medicare claims, enroll and educate providers on the Medicare program, and handle provider and beneficiary inquiries and claims appeals. According to the Centers for Medicare & Medicaid Services (CMS), the MACs and other Medicare claims administration contractors process nearly 4.9 million Medicare claims each business day and disburse more than $365 billion annually in program payments.

MACs also help oversee the development of Medicare polices and can issue local coverage determinations (LCDs), which dictate whether a particular item or service is covered and what requirements must be met for payment. For example, one recently proposed LCD included a requirement that multiple 12-week nonsurgical interventions be documented prior to authorizing coverage of a total joint replacement.

Luckily, that requirement didn’t go into effect—in large part because orthopaedic surgeons learned of it early and were able to mobilize efforts to have it rewritten. That early warning came from an orthopaedic representative on a local Carrier Advisory Committee (CAC).

The role of CACs
CMS requires each MAC to have a physician Contractor Medical Director (CMD), as well as one CAC per state for all states within its jurisdiction. If there is more than one insurance carrier in a state, the carriers are to jointly establish a CAC. Each CAC is composed of physicians from different specialties, including orthopaedics, who advise the MAC through the CMD.

According to CMS, CACs provide the following:

  • a formal mechanism for physicians in the state to be informed of and participate in the development of an LCD in an advisory capacity
  • a mechanism to discuss and improve administrative policies that are within carrier discretion
  • a forum for information exchange between carriers and physicians

Generally, CAC members serve to improve the relations and communication between Medicare and the physician community. Specifically, CAC members disseminate proposed LCDs to colleagues in their own state and specialty societies to solicit comments; disseminate information about the Medicare program obtained at CAC meetings to their state and specialty societies; and discuss inconsistent or conflicting medical review policies. Although the CAC reviews all draft LCDs, the final implementation decision about LCDs rests with the CMD.

“Serving as the orthopaedic representative for my CAC has allowed me to share the opinions of the orthopaedic community and help improve the Medicare program in my jurisdiction,” stated Brian S. Parsley, MD, who is the orthopaedic CAC representative for Texas. “Specialty physician input through the CAC process is vitally important to the development of appropriate local coverage determinations and the functioning of orthopaedic practices that rely on the Medicare program. Serving in the CAC process also allows us to monitor proposed changes within the regional MAC.”

Even though most LCDs will have nothing to do with orthopaedics, the ones that do can have major consequences. The proposed total joint replacement LCD, as well as efforts by MACs and their Recovery Audit Contractors (RACS) to recoup payments for procedures from physicians based on inadequate documentation of medical necessity, are just two examples.

As a result, the American Association of Orthopaedic Surgeons (AAOS) wants to ensure that every MAC has an orthopaedic representative advising it, in case one of these important orthopaedic coverage determinations arises. AAOS has taken several steps to ensure orthopaedic representation on CACs, including forming the Orthopaedic CAC Network.

The Orthopaedic CAC Network
Originally led by Fred Redfern, MD, the Orthopaedic CAC Network was created to facilitate communication between each state’s orthopaedic CAC representative and the AAOS. The network has helped compile information on CAC representatives in all of the states and identify those states with a vacant orthopaedic slot. AAOS has also reached out to the CMDs for help identifying states with orthopaedic vacancies.

The Board of Councilors Committee on State Legislative and Regulatory Issues (SLRI) has formed a subcommittee to facilitate communication between each state’s orthopaedic CAC representative and the AAOS. The subcommittee will help oversee this process and assist AAOS in recruiting CAC participants for states with vacancies.

“If we don’t voice concerns facing the orthopaedic community ourselves, other specialties or nonphysicians will be making those decisions,” stated Dr. Redfern. “It is important to ensure orthopaedic representation on each CAC, as well as to provide each orthopaedic surgeon with a consistent message regarding orthopaedic procedures for the CMD. This is why we created the Orthopaedic CAC Network and why close coordination and communication is absolutely essential as we move forward.”

CAC representative responsibilities
A CAC representative must attend three to four meetings a year and review proposed LCDs on all types of medical services. Additionally, AAOS encourages CAC members to report back to their state orthopaedic societies and the AAOS. Eboni Morris (
morris@aaos.org), the manager of state government affairs in the AAOS office of government relations, serves as the CAC liaison.

Nominating a CAC representative
The process for nominating a CAC representative for each state is relatively easy; self-nominations are acceptable. First, make sure the seat for an orthopaedic CAC representative in your state is vacant. The AAOS office of government relations can provide information on vacant seats.

Identify a volunteer—or nominate yourself—to fill the vacant slot. The state orthopaedic society board of directors should vote on the nomination. The state society should also contact the CMD to request appointment of the nominee to the state’s CAC. If a response is not forthcoming in a reasonable amount of time, contact the AAOS office of government relations. Once the nominee has been appointed, his or her name should be sent to Eboni Morris in the AAOS office of government affairs.

Elizabeth Fassbender is the communications specialist in the AAOS office of government affairs. For more information on orthopaedic representation on CACs, contact Eboni Morris, manager of state government affairs, at morris@aaos.org

Graphic:
The 10 consolidated Medicare A/B MAC jurisdictions