REIMBURSEMENT The Centers for Medicare and Medicaid Services (CMS) contracts with private insurers to process claims for Medicare beneficiaries. Insurers that process Medicare hospital claims are called “intermediaries,” while those that process Medicare physician claims are called “carriers.” By 2011, intermediaries and carriers will be replaced by Medicare Administrative Contractors (MACs). CMS plans to award 19 MAC contracts with 15 of these contracts to insurers that will cover the majority of hospital (Part A) and physician (Part B) services. As of November 2007, three A/B contracts have been awarded, with implementation for those three A/B MACs to begin Spring 2008. Currently, each intermediary and carrier has jurisdiction to create their own independent coverage policies in cases where a national coverage decision does not exist. The level of evidence required for a positive coverage decision varies by insurer. It is important to consider the level of evidence required by insurers when designing your clinical trial. As such, the opinion of one or more insurance medical directors can be of great assistance prior to finalizing your endpoints and clinical trial design. Contact RCRI®’s Director of Reimbursement, Monica Schultz, at 952-746-8721 to learn more about designing clinical trials for reimbursement purposes and/or help with identifying, and meeting with, insurance medical directors.NOTE: The information on this website is provided as background information only. Reimbursement strategy relies on more information and context than can be provided on one website. Therefore, Regulatory and Clinical Research Institute, Inc. specifically disclaims liability or responsibility for the results or consequences of any actions taken in reliance on information from this website.
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