Medicare Compliance & Reimbursement

New guidance documents take some guesswork out of the NCD process.

Are you frustrated by national coverage determinations that seem to be decided behind closed doors? Reform bill provisions could shed some much-needed light on the decision-making process.

A notice in the Sept. 24 Federal Register says that the Centers for Medicare & Medicaid Services will soon make guidance documents available on its Web site. These resources will help providers get a handle on the key factors CMS looks at when determining whether an item or service is reasonable and necessary. This includes:

the necessary content, implications and relevant timelines to note when making an NCD request;

types of scientific and other information that CMS will consider; and

how CMS evaluates various types of evidence and studies.

A word of caution from CMS: "The absence of a particular type of research (does not) necessarily result in a non-coverage decision, nor does submitting data from a particular type of study ensure coverage," the notice reads. "Each NCD involves unique factors that cannot be described explicitly in the guidance documents."

A public comment period will be set aside for each guidance document, which will be issued at http://www.cms.hhs.gov/coverage. To read the notice go to
http://www.access.gpo.gov/su_docs/fedreg/a040924c.html. 

Lesson Learned: Providers can expect a better understanding of - and have more voice in - CMS' NCD process.