Eli's Rehab Report

Published on Fri Aug 08, 2008 PDF

Your carriers and FIs will soon be a thing of the past if they aren't already.

You've heard CMS talking about all these newly awarded AB MAC contracts, and it's an easy subject to leave on the back burner if your carrier or FI hasn't changed. But before you know it, the transition will be in full swing, so get the scoop here.

Background: The Medicare Prescription Drug, Improvement and Modernization Act of 2003 calls for Medicare Contracting Reform -- which means a merging of Part A and Part B Medicare contractors (FIs and carriers). CMS' vision is to have more consolidated jurisdictions with one entity each that processes all Medicare claims. These entities, dubbed Medicare Administrative Contractors (MACs), have been slowly replacing carriers and FIs since 2006, and CMS hopes to have the new system live nationwide by 2011.

Most of the work will be on your carriers' or FIs' shoulders as they pass the buck to the new MACs, but there are a few things you can do to prepare.

CMS has already chosen MACs for eight of its 15 new jurisdictions. If you haven't been keeping up with what's going on in your jurisdiction, now's the time to start. "You need to know basic things such as where you'll be sending your claims in case there's an address change," points out Rick Gawenda, PT, director of PM&R for Detroit Receiving Hospital and owner of Gawenda Seminars. "You may also have to submit paperwork to get credentialed under your new MAC."

See the chart below for a list of the jurisdictions and who's been awarded contracts. If your jurisdiction has a MAC, check out the company's Web site and get acquainted, Gawenda suggests.

2. Study Your New LCD

Once you know who your new MAC is, if it's different from your current FI or carrier, you need to learn its policies and local coverage determinations. For example, Montana's FI and carrier was Blue Cross and Blue Shield of Montana. "In 2006, Noridian Administrative Services became the AB MAC for Jurisdiction 3 -- so therapy providers in Montana need to know coverage policies for PT, OT and SLP, which may be different from BCBS Montana," Gawenda says.

When you learn a new LCD, you'll also want to keep an eye out for different documentation requirements and any stipulations on using modifiers, points out Catherine Brink, CMM, CPC, president of HealthCare Resource Management in Spring Lake, N.J.

Even if you know your new MAC's LCD back and forth, there's one more piece to the story. When it comes time to switch from your old FI or carrier to the new MAC, there may be a small window of "downtime" when you cannot submit claims. "Here in New Jersey, Highmark is the new MAC, and it's alerted us that there will be a 3-day period of downtime as we transition from our carrier, National Government Services, to Highmark," Brink tells TCI. "It's not a huge imposition since it will be over a weekend, but it's something to be aware of."

Once the transition has happened, also be aware that your claims processing may have a slightly different timeframe than your old carrier or FI, Brink notes. "But the most important thing is to be aware of your new MAC's coverage policies."

Note: For more information on the MAC transition, visit http://www.cms.hhs.gov/MedicareContractingReform/.