Have you ever wondered why a clinical history of “lightheadedness” for a head CT leads to a harsh email from your coding and billing department, while “dizziness” is smooth sailing? Who decides what an appropriate history is for a radiological exam?

For Medicare billing, most of those decisions rest with the Medicare Administrative Contractors (MACs). Medicare is a huge, $683 billion enterprise. Therefore, due to Medicare’s sheer size, CMS is unable to process all the nationwide claims — so it divides the country up into several “jurisdictions.” It then puts up for bid the claims processing contracts for each jurisdiction. Private insurance companies then bid for each contract, which lasts for up to seven years. One of the conditions of the contract is that each MAC needs to convene a group of physicians from multiple specialties and seek their advice in deciding which symptoms, signs, and diseases are appropriate for particular medical exams or procedures. These groups are the Contractor Advisory Committees (CACs).

Prior to 2019, the MACs needed to constitute a CAC for each state, even if there happened to be ten states in one jurisdiction (for example, Jurisdiction F). These CACs met at least three times a year. During these meetings, the MACs proposed Local Coverage Determination (LCD) policies, which outlined the conditions under which they would reimburse providers for their services. The CAC meetings not only offered a forum for physicians to give feedback on these policies, but also provided an opportunity for physicians and the CAC medical directors to exchange ideas and concerns. The final decision on the LCDs still rested with the MACs, but the CAC meetings allowed the contractors to get a sense of what physicians felt. Within this complex system, the ACR sought opportunities to streamline processes and avoid duplicating efforts.

The MACs would usually introduce their proposed policies around the same time to all the states in their jurisdiction. However, there was no mechanism for the communication and coordination amongst the radiology CAC members — which resulted in a duplication of the work reviewing the LCDs and offering policy improvements. The ACR had the foresight to establish the CAC Network in 2001 under the leadership of Bibb Allen Jr., MD, FACR. Continuing under the leadership of Robert K. Zeman, MD, FACR, this collaboration served as a means for CAC members in radiology, nuclear medicine, and radiation oncology to share news about upcoming LCDs, divide up work reviewing the draft policies, and strategize actions to take.

Several changes took place to the LCD development process at the beginning of 2019. Under the 21st Century Cures Act, the purpose of the CAC was changed from reviewing the draft LCDs to analyzing the scientific literature that underpinned the policies. The LCDs were presented later, and CAC members no longer provided face-to-face feedback on the policies to the MACs. In addition, it was no longer mandated that each state have a full committee; a MAC could form one CAC per jurisdiction, or even collaborate with other MACs to form a multi-jurisdictional CAC. In the last year and a half, those multi-jurisdictional CACs have become the norm.

With these changes, the ACR CAC Network has become more critical now than ever. As the MACs have started working together, ACR CAC members need to leverage the framework the College established decades ago to coordinate efforts to respond to the coverage policies that the MACs put forth.