Hi all-
I'm not sure if anyone out there may have some experience or knowledge on how determinations work, but I'd love any insights that anyone has.
I live in Colorado. Our Medicare used to be administered by a company named Trailblazer, but in late 2012 they were replaced by Novitas, the company that administers the New England Medicare system. It seems that Novitas is (for now) keeping many of the Local Coverage Determinations originally put in place by Trailblazer.
In practical terms that creates sort of an odd situation. Certain treatments covered in New England are deemed "experimental" (and are not covered) in Colorado. According to the local coverage determinations, both the Colorado and New England jurisdictions are looking at the same studies. At the time the LCDs were put in place, Trailblazer and Novitas made different judgement calls for their respective regions. However, now Novitas is basically saying that if you live in New England, they'll cover it, but if you live in Colorado, you are out of luck- which seems rather arbitrary.
Does anyone know how this works? I know there is a "reconsideration" process for LCDs, but I don't know if patients or providers initiate them. I also don't know if an administrator in this situation is given a "grace period" to standardize its practices or if it is in fact allowed to deny and approve people solely on geographic location. I've tried to find a way to ask the administrator, but all their contact methods are reserved for "providers."
Does anyone know how the administrators work or where I can get info on policies for this sort of situation? Thanks!
I'm not sure if anyone out there may have some experience or knowledge on how determinations work, but I'd love any insights that anyone has.
I live in Colorado. Our Medicare used to be administered by a company named Trailblazer, but in late 2012 they were replaced by Novitas, the company that administers the New England Medicare system. It seems that Novitas is (for now) keeping many of the Local Coverage Determinations originally put in place by Trailblazer.
In practical terms that creates sort of an odd situation. Certain treatments covered in New England are deemed "experimental" (and are not covered) in Colorado. According to the local coverage determinations, both the Colorado and New England jurisdictions are looking at the same studies. At the time the LCDs were put in place, Trailblazer and Novitas made different judgement calls for their respective regions. However, now Novitas is basically saying that if you live in New England, they'll cover it, but if you live in Colorado, you are out of luck- which seems rather arbitrary.
Does anyone know how this works? I know there is a "reconsideration" process for LCDs, but I don't know if patients or providers initiate them. I also don't know if an administrator in this situation is given a "grace period" to standardize its practices or if it is in fact allowed to deny and approve people solely on geographic location. I've tried to find a way to ask the administrator, but all their contact methods are reserved for "providers."
Does anyone know how the administrators work or where I can get info on policies for this sort of situation? Thanks!