The federal government is being "too restrictive" in the number and scope of Medicare services for which physicians and patients can seek prior determination of coverage, said a letter recently sent by AAFP Board Chair Mary Frank, M.D., of Mill Valley, Calif., to CMS Administrator Mark McClellan, M.D., Ph.D.
CMS could reduce the number of retrospectively denied Medicare claims by letting physicians and patients seek prior determination of coverage for a wider range of services, noted Frank.
The Oct. 4 letter to McClellan was sent in response to a CMS proposal that would establish a system by which physicians and patients could learn -- before a service was provided -- whether Medicare would cover that service. The proposed rule, published in the Aug. 30 Federal Register (PDF file: 5 pages / 65 KB. More about PDFs.), would identify 50 services for which physicians could seek prior determination of coverage under Medicare. CMS would identify those services based on their cost, the frequency of their use, and whether local, regional or national data have already clearly defined that Medicare covers the service.
The proposed rule is a start, but it doesn't go far enough, said Frank in the letter. By limiting the list to 50 expensive and rarely used services, CMS effectively undercuts the law's intent and rules out prior determinations for services that are more commonly provided by family physicians and that are frequently denied coverage.
"We believe CMS has erred on the side of being too restrictive in setting the initial pool of eligible services" for prior determination, said Frank in the letter. "We think it would make more sense to include all services above a certain dollar amount (e.g., $100) ... rather than limiting it to the top 50 services based on average allowed charges," she added.
In addition, CMS should drop a provision that would exclude any physician service for prior determination status when CMS decides that local, regional or national coverage data already define whether that service should be covered by Medicare.
"From our perspective, the presumption that beneficiaries will access and understand either national or local coverage determinations is ludicrous," Frank said in the letter.
The ultimate result of the proposed rule would "effectively gut what would otherwise be a wonderful benefit to beneficiaries and their physicians by limiting its applicability in the extreme," Frank concluded.
