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staying informed and involvedIn the last three years we have experienced profound changes in cancer service delivery, coding, billing, reimbursement and regulations. The pace and complexity of these changes along with the knowledge that further changes are certain can lead to the perception that we have no voice in the future of cancer care in our communities. This is not the case. We have many opportunities to become actively involved in this process. Advocacy is defined as “active support.” To be an effective advocate for our patients and our practices we need to be educated on the issues affecting cancer care delivery and we need to actively participate in the process of determining how cancer care will be delivered and reimbursed in our communities. This special edition is a resource guide for staying informed and involved.
The Centers for Medicare and Medicaid Services Freedom
of Information Act The FOIA, enacted in 1966, can be found in Title 5 of the United States Code, section 552. The act provides access upon request to any non-privileged Federal agency record. Records that are specifically exempt from FOIA release are:
The CMS Web site and your Medicare Carrier’s Web site contain detailed instructions on the FOIA and how to request information under the act. Physicians most commonly request Medicare Part B charge and reimbursement information. A practical example of a recent request under the FOIA to a Medicare Carrier: A written request to a Medicare carrier under the FOIA described the USPDI listed unlabeled use of a particular drug, and cited the reference to the Medicare Carrier Manual section 2049.4C giving Medicare carriers the authority to extend coverage to unlabeled uses in specified compendia. The requestor asked the carrier whether the newly listed unlabeled use would be included in an update as a covered diagnosis by the carrier. The requestor also asked for the effective date of coverage and recommended coding and billing guidelines. Approximately 6 weeks later the Freedom of Information Coordinator for the Medicare carrier responded in writing with the affirmation of coverage for the unlabeled use of the drug and the primary and secondary diagnoses necessary for proper claim submission. The written confirmation of coverage and the primary and secondary diagnoses necessary for proper coding and billing received from the carrier on their letterhead provides support for the practice should there be an improper denial. Comment
on Proposed Regulations To view the document and comment electronically, click on Go in the column titled Submit Comment. At this point you must enter your postal code (zip code), country and choose the appropriate category from the drop down list, enter your name and that of your organization (optional) and hit enter. Read Electronic Comments on CMS Regulations sent in by other interested parties to gather information on the point of view of others in the oncology community. At Regulations.gov search for all CMS documents open for comment by clicking on Documents Open for Comment and choosing the Centers for Medicare and Medicaid Services in the drop-down menu. The Docket ID, Document ID, Document Title and the PDF and HTML version of the proposed rule open for comment will be displayed. Comments on the proposed rule may be submitted directly from this page. CMS publishes proposed rules and regulations in the Federal Register, the daily newspaper of the Federal government. The Federal Register is published Monday-Friday by the National Archives and Records Administration (NARA). All information in the Federal Register is public information and may be reproduced without restriction. Stay informed on the publication of these proposed regulations by signing up to receive the daily Federal Register Table of Contents on the Federal Register Main Page. The daily table of contents will be received by email. Scroll down the list to Centers for Medicare and Medicaid to see the daily list of notices and meetings pertaining to CMS. National
Coverage Determinations An NCD is binding to all Medicare contractors, Medicare Advantage Plans, quality improvement organizations and Administrative Law Judges. Comment
on Proposed Coverage Issue
In formulating your comments on specific issues it may be helpful to read the comments that have been submitted by other providers, professional organizations such as the American Society of Clinical Oncology (ASCO), the Association of Community Cancer Centers (ACCC) as well as those submitted by other interested industry members. Any party may request an NCD. According to CMS, a complete formal initial request for an NCD or formal request for reconsideration must include the following:
If you are not familiar with the NCD process, CMS encourages that you contact them informally prior to formally requesting an NCD. CMS can be contacted by email at cms_caginquiries@cms.hhs.gov. Local
Coverage Determinations The process under which LCDs are developed is defined in the Medicare Program Integrity Manual (PIM), chapter 13. Contractors are required to develop LCDs for the following situations:
Contractors may develop LCDs for other reasons, including these situations:
Medicare Part B contractors develop LCDs through the Contractor Advisory Committee (CAC) process described in this newsletter. However, under the following situations LCDs may be revised without requiring a comment and notice period:
Final LCDs may be considered for revision when new evidence is presented to the carrier by an interested party. A reconsideration request that would conflict with a NCD will not be reviewed. To submit a request for a LCD reconsideration, review the instructions on your Medicare carriers Web site. Open
Door Forums The forums are commonly attended by Carrier Medical Directors (CMDs), CMS personnel, providers, office administrators, billing managers, industry representatives and others interested in the particular forums topic. Audio files of Special Open Door Forums may also be available on the Open Door Forums Web page. Forum participants have an opportunity to learn from the discussion and to comment or ask questions related to the forum topic. For example, on January 24, 2006 CMS hosted a two-hour Open Door Forum on Medicare Part B and Part D coverage and payment. During this call participants had an opportunity to ask questions and request clarifications regarding the program. To be notified of upcoming forums by email register for the CMS Mailing Lists by choosing areas of interest. Once registered, you will be notified by email of upcoming forums.
Physicians
Regulatory Issues Team The PRIT is composed of CMS subject matter experts. Dr. William Rogers leads the team of CMS leadership staff, regional office staff, physicians and technical experts that make up the PRIT. Providers can view past and Active PRIT Issues and track their status by clicking on the issue on the PRIT Web page. An example of an issue that the PRIT addressed is the clarification of language in CMS Transmittal 788 regarding consultations. The following is from the PRIT Web page:
PRIT Contact
Information:
Contractor
Advisory Committee In the Medicare Program Integrity Manual (MPIM) Chapter 13 – Local Coverage Determinations CMS dictates that Medicare Carriers and Intermediaries present draft LCDs for public comment prior to presenting the draft policy to the Contractor Advisory Committee (CAC). Comments on draft policies can be submitted in writing, by email, through teleconference or in person at Open Meetings. Open Meetings are held prior to each CAC meeting allowing interested parties to present relevant information and comments regarding the draft LCD. Parties interested in making a presentation at one of these open meetings must register with their Medicare Carrier/Intermediary. Information on registering to present at an Open Meeting is available on the Medicare Contractor’s Web site. Draft LCDs requiring a comment period are open for comment for a minimum of 45 calendar days. After the comment period ends, a Final LCD is developed, and there is another 45 calendar day comment period on the Final LCD. All draft LCDs, the start and stop date of the comment period as well as information on how to comment on the policy must be posted on the contractor’s Web site. The American Society of Clinical Oncology (ASCO) maintains a list of hematology and oncology CAC members, State Hematology/Oncology Societies, Medicare Contractors, Medicare Carrier Medical Directors, and their contact information on their Web site. .................................................................................. Cancer Professional Advocacy Organizations Oncology advocacy organizations and their stated Mission Statements: The Association of Community Cancer Centers (ACCC) www.accc-cancer.org The American Society of Clinical Oncology (ASCO) www.asco.org
Oncology Nursing Society
................................................................................. ABOUT THE EDITOR .................................................................................. CONTACT US Oplinc .................................................................................. UPCOMING ISSUE .................................................................................. NEWSLETTER ARCHIVES
.................................................................................. IMPORTANT NOTICE
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State Societies State societies are particularly powerful voices for the oncology community. Many of these societies have developed strong cooperative partnerships with their Medicare Carrier Medical Director (CMD) and insurance companies. These societies provide many services to their members including:
State societies provide a vehicle for grassroots efforts on issues benefiting patients and providers. Become an engaged and active member in your state oncology/hematology society. State Medical Societies These societies provide members with resources and tools including practice forms, form letters for correspondence with payers, publications dealing with practice management and reimbursement, and state legislative contacts. Additionally, most state medical associations have lobbying and legal staff. In the state of Washington, the state medical association, Washington State Medical Association (WSMA) has been assisting the Washington State Medical Oncology Society (WSMOS) in their efforts to repeal the 1.5% Business and Occupation tax that oncologists pay on their drug receipts. State Societies Alabama Medical Association of the State of Alabama ............................................... Alaska Alaska State Medical Association ............................................... Arizona ............................................... Arkansas ............................................... California Medical Oncology Association of Southern California California Medical Association ............................................... Colorado ............................................... Connecticut Oncology Network of Connecticut, LLC Connecticut State Medical Society ............................................... Delaware ............................................... District of Columbia Medical Society of the District of Columbia ............................................... Florida ............................................... Georgia Medical Association of Georgia ............................................... Hawaii ............................................... Idaho Society of Administrators in Medical Oncology-Northwest ............................................... Illinois Illinois State Medical Society ............................................... Indiana Indiana State Medical Association ............................................... ............................................... Kansas ............................................... Kentucky ............................................... Louisiana Louisiana State Medical Society ............................................... Maine ............................................... Maryland Maryland State Medical Society ............................................... Massachusetts ............................................... Michigan Michigan State Medical Society ............................................... Minnesota ............................................... Mississippi Mississippi State Medical Association ............................................... Missouri Missouri State Medical Association ............................................... Montana Society of Administrators in Medical Oncology-Northwest ............................................... Nebraska ............................................... Nevada Nevada State Medical Association ............................................... New
Hampshire ............................................... New Jersey New Jersey Society of Oncology Managers ............................................... New
Mexico ............................................... New
York New York Association of Oncology & Hematology Practice Administrators Medical Society of the State of NY ............................................... North
Carolina North Carolina Medical Society ............................................... North Dakota North Dakota Medical Association ............................................... Ohio Ohio State Medical Association ............................................... Oklahoma Oklahoma State Medical Association ............................................... Oregon Society of Administrators in Medical Oncology-Northwest ............................................... Pennsylvania Pennsylvania Oncology Hematology Managers’ Society ............................................... Rhode
Island ............................................... South
Carolina South Carolina Medical Association ............................................... South
Dakota South Dakota State Medical Association ............................................... Tennessee ............................................... Texas ............................................... Utah ............................................... Vermont ............................................... Virginia Virginia Association of Hematology Oncology Managers ............................................... Washington Society of Administrators in Medical Oncology-Northwest Washington State Medical Association ............................................... West Virginia West Virginia State Medical Association ............................................... Wisconsin ............................................... Wyoming
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Another
opportunity to comment occurs when a Proposed Decision Memo (PDM) is issued.
There is a 30 day public comment period on PDMs. This comment period may be
used to offer informed opinions, provide additional information and insights on
the issue and to request clarification of posted information. 
