ASRA Practice Management Lexicon

Criteria used to establish that health care provided is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Explanation

Third party payers, including insurance companies and the government, establish criteria that must be met for a service or product to be considered reasonable and necessary. Elements generally include evidence that an intervention is expected to improve a patient’s condition, is consistent with nationally recognized standards, is appropriate for meeting the patient’s individual needs, is not primarily motivated by convenience, and is not more costly than equivalent services. There is no universal agreement on what constitutes medical necessity. Providers should consult with the payers they contract with to determine the specific criteria for each payer.

Example of Applicable Legislation/Regulation

Centers for Medicare & Medicaid Services issues national coverage determinations that specify whether interventions are considered reasonable and necessary.

Reference

Medicare Program Integrity Manual: chapter 3 - verifying potential errors and taking corrective actions. Centers for Medicare & Medicaid Services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf. Accessed January 4, 2019.

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Local Coverage Determination

Definition

Defined in the Social Security Act as a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis under such parts, in accordance with section 1862(a)(1)(A).

Explanation

Each Medicare contractor is given the discretion to determine which services are reasonable, necessary, and covered under its policies. Contractors provide lists of local coverage determinations, including descriptions of covered services and required documentation. Centers for Medicare & Medicaid Services made significant changes to local coverage determinations in October 2018.

Example of Applicable Legislation/Regulation

Medicare

References

Local coverage determinations. Centers for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Coverage/DeterminationProcess/LCDs.html. Accessed January 4, 2019.

Local coverage determinations (LCDs) by state index. Centers for Medicare & Medicaid Services. https://www.cms.gov/medicare-coverage-database/indexes/lcd-state-index.aspx. Accessed January 4, 2019.

Summary of significant changes to the Medicare Program Integrity Manual chapter 13 - local coverage determinations. Centers for Medicare & Medicaid Services. https://www.cms.gov/newsroom/fact-sheets/summary-significant-changes-medicare-program-integrity-manual-chapter-13-local-coverage. Accessed January 4, 2019.

Medicare Program Integrity Manual: chapter 13 - local coverage determinations. Centers for Medicare & Medicaid Services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c13.pdf. Accessed January 4, 2019.

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Medicare Administrative Contractor (MAC)

Definition

A Medicare Administrative Contractor (MAC) is a private company that has been awarded a contract to process Medicare A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-for-Service (FFS) beneficiaries for a geographic jurisdiction.

Explanation

CMS relies on a network of MACs to serve as the primary operational contact between the Medicare FFS program and the health care providers enrolled in the program. MACs are multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims. MACs perform many activities including the following:

Process Medicare FFS claims
Make and account for Medicare FFS payments
Enroll providers in the Medicare FFS program
Handle provider reimbursement services and audit institutional provider cost reports
Handle redetermination requests
Respond to provider inquiries
Educate providers about Medicare FFS billing requirements
Establish local coverage determinations (LCDs)
Review medical records for selected claims
Coordinate with CMS and other FFS contractors

Currently there are 12 A/B MACs and 4 DME Macs in the program that process Medicare FFS claims for nearly 60% of the total Medicare beneficiary population, or 37.5 million Medicare FFS beneficiaries.

Example of Applicable Legislation/Regulation

Medicare: Section 911 of the Medicare Prescription Drug Improvement, and Modernization Act (MMA) of 2003 (Public Law 108-173) directed CMS to replace the Part A Fiscal Intermediaries (FIs) and Part B carriers with MACs.

Reference:

Centers for Medicare and Medicaid Services. What is a MAC. Last updated 12/18/2020. Accessed from https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/What-is-a-MAC on June 28, 2021.

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Contractor Advisory Committee (CAC)

Definition

A Contractor Advisory Committee (CAC) is a committee established by a Medicare Administrative Contractor (MAC) to provide a formal mechanism for healthcare professionals to be informed of the evidence used in developing a Local Coverage Determination (LCD) and to promote communications between the MAC and the healthcare community.

Explanation

MACs are required to establish CACs to advise in the development of LCDs. MACs may establish one CAC per state, or they also have the option of establishing one CAC per jurisdiction or a multi-jurisdictional CAC. In the latter cases, MACs are required to endeavor to ensure that each state has a full committee and the opportunity to discuss the quality of evidence used to make a determination.

CACs are expected to serve in an advisory capacity as representatives of their constituency, on a voluntary basis. They are to be composed of healthcare professionals, beneficiary representatives, and representatives of medical organizations. CACs are used to supplement the MACs’ internal expertise and to help ensure an unbiased and contemporary consideration of “state of the art” technology and science.

CAC meetings are open to the public, although some portions not discussing evidence for a proposed LCD may be closed to the public. Meetings may be in-person and/or telephonic/video/on-line, and they must be recorded, with recordings posted on MACs’ websites.

Example of Applicable Legislation/Regulation

Medicare: Centers for Medicare and Medicaid Services. Medicare Program Integrity Manual, Chapter 13. Revision 863, Revised 02-12-2019. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c13.pdf. Accessed July 6, 2021.

References

Centers for Medicare and Medicaid Services. Medicare Program Integrity Manual, Chapter 13. Revision 863, Revised 02-12-2019. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c13.pdf. Accessed July 6, 2021.

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Bundled Payment

Definition

Providers received a fixed payment, or bundle, for a specific episode of care delivered within a specified time-frame.

Explanation

An episode of care includes all health care provided for a specific procedure or event for a specified period of time. It includes all acute care, procedures, and post-acute care provided by all hospitals, health care professionals, rehabilitation facilities, skilled nursing facilities, and any other providers or facilities providing care. Providers receive a fixed payment. If the actual costs of providing care are less than the bundled payment, then providers keep the savings. If actual costs are higher than the bundled payment, then providers must cover those costs. Under some plans, payers reimburse each provider separately while keeping total reimbursement at the fixed rate. Under other plans, payers make a single payment to one provider or organization that subsequently pays all the other providers participating in care.

Example of Applicable Legislation/Regulation

Centers for Medicare & Medicaid services currently incorporates specific episodes of care in its bundled payment model.

References

BPCI advanced. Centers for Medicare & Medicaid Services. https://innovation.cms.gov/initiatives/bpci-advanced. Accessed January 4, 2019.

Bundled payments for care improvement (BPCI) initiative: general information. Centers for Medicare & Medicaid Services. https://innovation.cms.gov/initiatives/bundled-payments/. Accessed January 4, 2019.

Navathe AS, Troxel AB, Liao JM, et al. Cost of joint replacement using bundled payment models. JAMA Intern Med. 2017;177(2):214-222.

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Value-Based Contracts

Definition

Providers are paid based on the quality of care delivered, as opposed to quantity of care under fee-for-service contracts.

Explanation

Under traditional fee-for service programs, providers bill and are paid for each service provided. Value-based programs, also known as pay-for-performance, link reimbursement to provider performance on quality measures. Each value-based program specifies the measures, scoring methodology, and payment reduction scale used in the program.

Example of Applicable Legislation/Regulation

Centers for Medicare & Medicaid Services offers the following value-based programs:

End-Stage Renal Disease Quality Incentive Program
Hospital Value-Based Purchasing Program
Hospital Readmission Reduction Program
Value Modifier Program (also called the Physician Value-Based Modifier or PVBM)
Hospital Acquired Conditions Reduction Program
Skilled Nursing Facility Value-Based Program
Home Health Value Based Program

References

What are the value-based programs? Centers for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs.html. Accessed January 4, 2019.

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One/Two-Sided Risk Contracts

Definition

In one-sided risk models, also called upside risk models, providers share in cost savings resulting from efficient provision of care and lowered costs, but face no risk if costs are high. In two-sided risk contracts, providers take on part of the financial risk of high costs as well as the benefits of cost savings.

Explanation

Incorporation of alternative payment models is shifting financial risk away from payers and onto providers. Two-sided risk contracts incentivize providers to maximize efficiency in delivery of care in order to reduce financial risk incurred from high health care costs and to benefit from shared cost savings. The intent is to hold providers accountable for the cost and efficiency of health care delivery. If health care is provided at a cost below a payer-set threshold, the provider(s) receive a percentage of the savings. Providers are financially penalized for costs above the threshold.

Example of Applicable Legislation/Regulation

Centers for Medicare & Medicaid Services issued a new Final Rule in December 2018 for Accountable Care Organizations under the Medicare Shared Savings Program.

References

Final Rule Creates Pathways to Success for the Medicare Shared Savings Program. Centers for Medicare & Medicaid Services. https://www.cms.gov/newsroom/fact-sheets/final-rule-creates-pathways-success-medicare-shared-savings-program. Accessed January 4, 2019.

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Narrow Networks

Definition

Insurance plans that include a limited and restricted pool of covered physicians and facilities. Networks are generally considered narrow if they incorporate less than 25% to 30% of providers in a given area compared with up to 70% of providers in more traditional, broader networks.

Explanation

Many insurers incorporate health care provider networks to reduce premiums. Insurers negotiate lower fees with physicians and facilities in exchange for inclusion in the network. Patients who seek medical care from physicians and facilities outside the network face increased costs. Narrow networks include a smaller percentage of physicians and facilities in an area than traditional networks and generally negotiate lower fees which, in turn, allow for lower premiums. Consumers who select plans based on price may not be aware of how limited their in-network options may be.

Example of Applicable Legislation/Regulation

Many plans offered under the Affordable Care Act exchange market feature narrow networks. Some of these narrow networks are limited in specialty coverage. Insurance companies are required to provide directories of providers associated with each plan. Consumers must research the directories to ensure access to needed providers.

Many plans sold to seniors through the Medicare Advantage program incorporate narrow networks.

References

Dafny LS, Hendel I, Marone V, Ody C. Narrow networks on the health insurance marketplaces: prevalence, pricing, and the cost of network breadth. Health Aff (Millwood). 2017;36(9):1606-1614.

Polski D, Weiner J, Zhang Y. Narrow networks on the individual marketplace in 2017. LDI Issue Brief. 2017;21(8):1-6.

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Reference Pricing

Medical Definition

All items in a class of roughly equivalent products or services are reimbursed at a fixed price.

Business Definition

Setting a price of a product or service below a competitor’s price or offering high discounts from a company’s own prices. The competitor’s price or company’s initial price serves as the reference price. The lower price appears to be a good deal compared with the reference price.

Explanation

Patients or providers who agree to use standard services or products receive full reimbursement. Those who choose to use more expensive products or services pay the difference, or a percentage of the difference, between the reference price and the actual price of the product or service. Reference pricing incentivizes, but does not require, use of lower-cost alternatives for products and services (eg, generic medications vs newer expensive medications, performance of procedures in an ambulatory surgery center vs hospital).

Example of Applicable Legislation/Regulation

In 2016, the state of Montana implemented reference pricing in its contracts with hospitals for state employee health care (currently not city, county, or university employees). The state currently pays an average of 234% of Medicare rates for services.

References

Acosta A, Ciapponi A, Aaserud M, et al. Pharmaceutical policies: effects of reference pricing, other pricing, and purchasing policies. Cochrane Database Syst Rev. 2014(10):CD005979.

Galizzi MM, Ghislandi S, Miraldo M. Effects of reference pricing in pharmaceutical markets: a review. Pharmacoeconomics. 2011;29(1):17-33.

Lee JL, Fischer MA, Shrank WH, Polinski JM, Choudhry NK. A systematic review of reference pricing: implications for US prescription drug spending. Am J Manag Care. 2012;18(11):e429-437.

The Free Dictionary by Farlex. https://medical-dictionary.thefreedictionary.com/reference+pricing. Accessed January 4, 2019.

Reference Pricing in Health Insurance. Berkeley Center for Health Technology. https://bcht.berkeley.edu/sites/default/files/utah_reference_pricing_082916.pdf. Accessed January 4, 2019.

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Definition

A Recovery Audit Contractor (RAC) is a company that has contracted with the Centers for Medicare and Medicaid Services (CMS) to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on health care services provided to Medicare beneficiaries, as well as to identify underpayments to providers.

Explanation

CMS contracts with RACs, which are authorized to review claims on a post-payment basis and to recoup overpayments. RACs are paid on a contingency basis such that, generally, they receive payments based on the amount of improper payments they identify and recoup; they may also receive payment related to underpayments identified.

The current RACs are identified on the CMS RAC website.

RACs can review any type of Medicare Part A or B claim, provided the service is included under an Approved RAC Topic. However, RACS may only review claims up to three years after the original claim paid date documented in the Common Working File.

Example of Applicable Legislation/Regulation

Medicare: Section 1893(h) of the Social Security Act authorized the Recovery Audit Program on a nationwide basis.

References

Centers for Medicare and Medicaid Services. Medicare Fee-for-Service Recovery Audit Program. Last modified April 22, 2021. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program. Accessed July 6, 2021.

Centers for Medicare and Medicaid Services. Resources. Last modified April 22, 2021. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Resources. Accessed July 6, 2021.

Centers for Medicare and Medicaid Services. Statement of Work (SOW) for the Part A/B Medicare Fee-for-Service Recovery Audit Contractor (RAC) – Region 1. March 26, 2021. https://www.cms.gov/files/document/rac-sow-region-1-march-26-2021.pdf. Accessed June 2, 2021.

Centers for Medicare and Medicaid Services. Statement of Work (SOW) for the Part A/B Medicare Fee-for-Service Recovery Audit Program – Regions 1-4. November 30, 2016. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/RAC-SOW-Regions-1-4-clean-November-30-2016.pdf. Accessed June 2, 2021.

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CAC Designated Organization (CDO)

Definition

A certified application counselor designated organization (CAC Designated Organization, or CDO) is an organization that is contracted with a health insurance Exchange to certify its staff members or volunteers to act as certified application counselors who perform the duties and meet the standards and requirements for certified application counselors, as specified in regulation.

Explanation

A CDO must enter into an agreement with an Exchange to comply with specified standards and requirements; maintain a registration process and method to track the performance of certified application counselors; and provide data and information to the Exchange regarding the number and performance of its certified application counselors.

Per regulation, certified application counselors are certified to:

(1) Provide information to individuals and employees about the full range of [Qualified Health Plan, or QHP] options and insurance affordability programs for which they are eligible, which includes: providing fair, impartial, and accurate information that assists consumers with submitting the eligibility application; clarifying the distinctions among health coverage options, including QHPs; and helping consumers make informed decisions during the health coverage selection process;

(2) Assist individuals and employees to apply for coverage in a QHP through the Exchange and for insurance affordability programs; and

(3) Help to facilitate enrollment of eligible individuals in QHPs and insurance affordability programs.

Example of Applicable Legislation/Regulation

Patient Protection and Affordable Care Act of 2010

CMS regulations at 45 CFR §155.225 detail requirements for certified application counselors and CDOs.

References

Centers for Medicare and Medicaid Services. Certified application counselor designated organization (CDO) program information. https://marketplace.cms.gov/certified-application-counselor-designated-organization-cdo-program-information. Accessed July 8, 2021.

Department of Health and Human Services. Certified application counselors. 45 CFR §155.225. https://www.govinfo.gov/app/collection/cfr. Accessed July 8, 2021.

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