Title: Anti-Kickback Implications of Ambulance Restocking
Author: PKURLAND
Last saved by: Pennsylvania State University
Company: American Medical Association

B of T Rep. 27 – A-99 – page

REPORT OF THE BOARD OF TRUSTEES

B of T Report 27 – A-99

Subject:	Medicare Carrier Model Policies
	
Presented by:		Randolph D. Smoak, Jr., MD, Chair

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BACKGROUND

At the 1998 Interim Meeting, the House of Delegates referred to the Board of Trustees for decision, as amended, Resolution 102, calling for the American Medical Association (AMA) to ask the Health Care Financing Administration (HCFA) to:

•	require that Medicare Part B payment policies be based on current clinical research or outcomes data, when available;

•	seek feedback from appropriate specialty organizations that are members of the carrier advisory committees;

•	rely more on national policies than on model policies adopted from carriers;

•	provide timely advance notice of changes in Part B policies; and

•	post carrier policies that are serving as models on the HCFA Web site, so that they will be accessible to interested parties.

This informational report provides an update on AMA activities specific to this issue.

Consistent with AMA Policies H-330.926 “Reform of HCFA Technology Assessment Process,” H-335.969 “Medicare Inappropriate Denial of Payment for Medically Necessary Services,” and H-185.975 “Requiring Third Party Reimbursement Methodology Be Published for Physicians,” the AMA has already been engaged in aggressive advocacy efforts addressing these issues.  The AMA has convened multiple meetings with HCFA staff and members of the Federation to discuss the process and criteria for developing local, national, and model Medicare coverage policies.  
The AMA participated in a HCFA “Town Hall” meeting on Medicare coverage policy held on September 25, 1998.  On November 17, 1998, as a follow-up to this Town Hall meeting, the AMA and more than 30 national medical specialty societies submitted a joint comment letter to HCFA with recommendations for reform of Medicare’s coverage policy decision process.

There has also been considerable interest among Members of Congress in reforming Medicare’s coverage process.  On April 22, 1999, the AMA presented testimony at a hearing on Medicare coverage decisions and beneficiary appeals convened by the Health Subcommittee of the House Ways and Means Committee on this issue.  In preparation for this hearing, the AMA sought examples from the national medical specialty societies of faulty Medicare coverage policies that had been established by local and regional Medicare carriers.  AMA testimony included examples of policies promoting routine denials of claims for nursing home visits, and those denying coverage of exams to clear patients for surgery based on a rationale that these are “screening” services.

DISCUSSION

As required by the above-referenced policies, AMA advocacy on Medicare coverage policy has sought to ensure that, whenever possible, coverage decisions are based on scientific evidence of clinical effectiveness, and that practicing physicians, particularly the national medical specialty societies, are consulted in the development of new policies.  The AMA has also sought to prevent HCFA from converting the coverage policy process into one more means of addressing Medicare “waste, fraud, and abuse” instead of clinical effectiveness.  Also, of all the various groups engaged in the Medicare coverage policy debate, such as medical device manufacturers, the AMA and specialty societies have taken the lead in advocating that the new standards being developed for coverage policy decisions be applied to local carrier policies, not just national policies.  The AMA has called for standards to be put in place for both local and national coverage policy decisions, including timeliness, openness, evidence-based decisions, accountability, and dissemination of information about new and revised policies to physicians. Finally, the physician community has been outspoken in its criticism of the model policy process.

These efforts have already met with considerable success.  On December 14, 1998, HCFA published a notice describing its plans to form a Medicare Coverage Advisory Committee (MCAC) and provided a Charter for the new committee to Congress.  The Charter indicates that HCFA will seek advice from the MCAC on scientific evidence of clinical effectiveness, and that the voting members of the committee will be individuals with expertise in clinical practice and research.  HCFA has also developed a new informational tracking system on coverage policies, which is available on the HCFA Web site. There is also growing recognition that the manufacturer community needs to work more cooperatively with organized medicine to achieve our shared goals of fostering improvements in medical technology and clinical practice and ensuring that positive innovations are accessible to patients insured by the Medicare program.  There is also growing recognition of the need for HCFA to keep its coverage policy activities separate from its fraud and abuse activities.  In February 1999, the Chairman and Ranking Member of the House Ways and Means Health Subcommittee sent a letter to the HCFA Administrator underscoring this point.

On the basis of this review, the Board decided that ongoing efforts to advocate AMA Policies H-330.926, H-335.969, and H-185.975 carry out the intent of Resolution 102 (I-98).