Contractor Medical Director (CMD)

1.4 - Contractor Medical Director (CMD) (Rev. 508; Issued: 03-07-14, Effective: 04-08-14, Implementation: 04-08-14) MACs: The MACs shall employ a minimum of two FTEs contractor medical director (CMD) and arrange for an alternate when the CMD is unavailable for extended periods. The CMD FTEs shall be composed of either a Doctor of Medicine or a Doctor of Osteopathy. All clinicians employed or retained as consultants shall be currently licensed to practice medicine in the United States, and the contractor shall periodically verify that the license is current. When recruiting CMDs, contractors shall give preference to physicians who have patient care experience and are actively involved in the practice of medicine. The CMD's duties are listed below. Primary duties include: • Leadership in the provider community, including: o Interacting with medical societies and peer groups; o Educating providers, individually or as a group, regarding identified problems or LCDs; and o Acting as co-chair of the Contractor Advisory Committee (CAC) (see chapter 13 §13.8.1.4 of this manual for co-chair responsibilities). • Providing the clinical expertise and judgment to develop LCDs and internal MR guidelines: o Serving as a readily available source of medical information to provide guidance in questionable claims review situations; o Determining when LCDs are needed or must be revised to address program abuse; o Assuring that LCDs and associated internal guidelines are appropriate; o Briefing and directing personnel on the correct application of policy during claim adjudication, including through written internal claim review guidelines; o Selecting consultants licensed in the pertinent fields of medicine for expert input into the development of LCDs and internal guidelines; o Keeping abreast of medical practice and technology changes that may result in improper billing or program abuse; o Providing the clinical expertise and judgment to effectively focus MR on areas of potential fraud and abuse; and o Serving as a readily available source of medical information to provide guidance in questionable situations. Other duties include: • Interacting with the CMDs at other contractors to share information on potential problem areas; • Participating in CMD clinical workgroups, as appropriate; and Upon request, providing input to CO on national coverage and payment policy, including recommendations for relative value unit (RVU) assignments. SMRC: Primary duties include: • Serving as a readily available source of medical information to provide guidance in questionable claims review situations • Providing the clinical expertise and judgment to develop LCDs and internal MR guidelines • Keeping abreast of medical practice and technology changes that may result in improper billing or program abuse • Providing clinical expertise and judgment to effectively focus MR on areas of potential fraud and abuse • Serving as a readily available source of medical information to provide guidance in questionable situations