Frequently Asked Questions - CAC

A Contractor Advisory Committee (CAC) is a federally mandated regional committee that enables pathologists to provide input on regional policies (called Local Coverage Determinations or LCDs) and patient care that comes under Medicare.

Although Medicare is a federal program, much of the policy setting, and most of the payment processing, and utilization reviewing is within the purview of a regionally contracted Medicare Administrative Contractor (MAC).

MAC jurisdictions are regional administrative domains. These are usually administered under contract to Medicare by divisions of large health care insurance companies. Each MAC has at least one medical director and an administrative staff.

The CAC is advisory in nature. The final decision on LCDs rests with the Contractor Medical Director (CMD). Historically, CMDs have been highly responsive to the suggestions from the CAC.

The CAC is composed of the MAC medical director and physicians from each medical specialty group, as well as representatives from medical societies, beneficiary representatives, and representatives of medical organizations. The minimum composition of a CAC is mandated by CMS and includes one physician representative from each of the major medical specialties and a designated alternate approved by the MAC. Physician representatives are nominated by their specialty societies. The length of service is specified by the MAC or by the nominating specialty.

MACs have the discretion to determine the frequency of CAC meetings and base their meetings on the appropriateness and volume of LCDs that require CAC consultation.

Contractors have the option of hosting in-person or telephonic/videoconference CAC meetings. The meetings are recorded (video, audio or both) and posted to the contractor website as part of the LCD record.

CAC meetings are also open to members of the public to attend and observe.

As a CAC representative in your state you gain a voice. The pathology community and you have the opportunity to shape the environment in which pathologists practice. Being a CAC representative is a service to fellow pathologists and your medical colleagues.

The time commitment is minimal, based upon the number of meetings each year. If you cannot attend an approved alternate may attend in your place.

• Review of the scientific evidence supporting the clinical indications for the item or service being considered for coverage;
• Communicate between practitioners and administrators/policy setters, with the CAC member as the communicating medium;
• At times the contractor staff or Medical Director may seek help in education or review of data and claims from other health care providers—this is an optional service
• Share relevant information with their state and national specialty societies.

The actual mechanics of these processes are flexible and context-dependent. For details, please contact:

Nonda Wilson, MS
Manager, Professional Affairs
Phone: (202) 354-7116
Email: nwilson@cap.org

You can also browse Centers for Medicare & Medicaid Services (CMS) web resources, such as the Medicare Program Integrity Manual, Chapter 13: Local Coverage Determinations.

Contractors have discretion to establish the duration of membership on the committee.

Representatives should consider a minimum term of 2-3 years to learn about the process and enhance the level of participation.

You will be able to voice balanced opinions on medical coverage policies that directly affect pathology as a profession. In the arena of health care, this is an interactive effort at education, shared awareness of contemporary issues, and an opportunity for learning.

CACs serve as a forum for discussion of Medicare policy at the regional level and on issues concerning pathology payment and provider education.

Issues that are not otherwise prominent within the working routines of contractor staff may gain helpful attention. For example, questions may be addressed about appropriate use of pathology studies, reimbursement for same date-of-service procedures, and outside consults.

CAC members can serve as a conduit for bringing concerns of their state society or the CAP to the attention of the contractors.

CAC representatives may be able to participate by teleconference or designate an alternate member to attend.

Contractors select committee representatives from names recommended by state specialty or medical societies. If a Contractor Medical Director (CMD) is concerned because of identified utilization/MR problems with an individual who has been recommended as a committee representative, the CMD should discuss the recommendation with the nominating body. If there is no organized specialty society for a particular specialty, the CMD should work with the State medical society to determine how the specialty is to be represented.

• Physician members must be actively practicing medicine and treating Medicare beneficiaries.
• Members’ utilization statistics and practice patterns must demonstrate that they compare favorably to those of their peers in the same specialty and practice.
• Members must not be the subject of an active investigation by law enforcement agencies.
• Members must not be the subject of a contractor fraud referral to law enforcement for investigation/prosecution.
• Candidates must be nominated by their societies in writing. The contractor requests that the societies nominate two candidates for each position. The standard term will be three years; however, societies may nominate their representatives for an additional term, at the discretion of the CMD. Nominees should represent the broad practice of the entire organization.
• Periodically, the CMD will confirm the CAC membership with each society.
• CAC Co-Chair - The CAC will be co-chaired by the contractor Medical Director and one physician selected by the committee.
• Members or their alternates should attend all meetings.   

The CAP keeps a listing of pathology CAC representatives and maintains a limited-access coverage website for pathology CAC representatives. If you need your representative's name and/or contact information, please contact:

Nonda Wilson, MS
Manager, Professional Affairs
Phone: (202) 354-7116
Email: nwilson@cap.org