New Medicare Legislation Vital to Chiropractic: FAQs
Thursday, June 25, 2015 09:22 AM

Quick Brief:  IMPORTANT:  Repealing the SGR system, in place for nearly 20 years, means that chiropractic physicians will no longer fear double digit cuts in reimbursement every year. However, there were other provisions in the bill that will also affect doctors of chiropractic.  This FAQ from the ACA explains more about this new law.

 

In midApril, the Congress passed, and the president signed, sweeping legislation designed to repeal the flawed Sustainable Growth Rate (SGR) formula used to determine provider reimbursement levels under the federal Medicare program. The plan would give physicians treating Medicare patients, including doctors of chiropractic (DCs), an annual payment increase of 0.5 percent for the next five years, with valuebased payments starting after that time.  For years, the imposition of the SGR payment formula threatened to produce unsustainable reductions in Medicare payment levels for all Medicare providers. Congress was repeatedly forced to enact a series of temporary postponements to avoid the full brunt of the payment reductions from taking place.

Repealing the SGR system, in place for nearly 20 years, means that chiropractic physicians will no longer fear double digit cuts in reimbursement every year. However, there were other provisions in the bill that will also affect doctors of chiropractic.

Q: I’m hearing a lot about the term “PIMA.” What is that?

A: Washington is very big on acronyms and “PIMA” is the Protecting the Integrity of Medicare Act, a series of provisions that were also included to the SGR bill, one of which directs the U.S. Department of Health and Human Services (HHS) to develop an education program to help improve documentation in chiropractic Medicare claims. The provision stipulates that the program would be created in consultation with ACA and Medicare Administrative Contractors (MACs).

Q: Why are DCs being singled out here?

A: This is part of an ongoing federal effort to reduce Medicare claim error rates. Chiropractic claims error rates in Medicare rank the highest of any provider group. Data from last year show that 54 percent of chiropractic Medicare claims were improperly paid with over 92 percent of the errors attributed to insufficient documentation. The HHS Office of the Inspector General (OIG), the department’s watchdog agency, has issued several reports in past years which also decry chiropractic documentation error rates. This provision will provide the ACA the opportunity to create education resources for those who are not compliant with clinical decisionmaking and documentation of the Medicare patient and at the same time, it will also offer ACA the opportunity to better interact with CMS and the individual MACs to provide a better understanding of our unique model of patient care.

Q: What does the PIMA provision include?

A: Along with the education component mentioned above, DCs whose claim denial rates are out of line with the rest of the profession could be subject to preauthorization standards established by HHS. DCs with a good record of claims based on proper documentation and those who avail themselves to the education program will avoid preauthorization requirements that noncompliant providers could eventually face.

Q: What will happen first?

A: The education component will be made available to DCs before any pre‐authorization system goes into effect.

Q: When is this education program scheduled to be available?

A: The legislation states that the education program be implemented and available by January 1, 2016.

Q: I’m hearing that the ACA is specifically mentioned in the bill as a stakeholder; is that true?

A: ACA’s lobby team worked with congressional members and staff to ensure the legislation was balanced and that all DCs were not unfairly scrutinized. The original version of the legislation, which ACA first saw in late summer of 2014, was much more draconian and would adversely affect chiropractic patients. ACA is seen by congress as the “go‐to” chiropractic association in Washington and ACA spent much time and resources in our negotiations on Capitol Hill.

Q: So if my Medicare claims documentation falls out of the top 85 percent of the profession, how will I, and more importantly my patients, be affected?

A: Under the PIMA provision, DCs whose claim denial rates are out of line with the rest of the profession could be subject to pre‐authorization standards established by HHS. DCs with a good record of claims based on proper documentation and those who avail themselves to the education program will avoid pre‐authorization requirements that non‐compliant providers could eventually face.

Q: The Medicare documentation trainer my state association uses, is excellent. Will we still be able to use that person in the future?

A: That should certainly still be the case. The education protocol developed will have a “seal of approval” from HHS and individuals who teach Medicare documentation should want to utilize that material. It is the intention of the ACA to make cooperating state associations full partners working with us to ensure that that Medicare claims error rates are reduced significantly.

Q: Are there any other provisions of this new law that I should be concerned about?

A: Another provision of interest to the profession is the Merit‐Based Incentive Payment System (MIPS). Beginning in 2019, the three existing quality incentive programs ‐‐ Physician Quality Reporting System (PQRS), EHR Meaningful Use and the Value‐Based Modifier ‐‐ will be consolidated into one cohesive program that streamlines reporting and avoids redundancies. Future payments will be adjusted based on provider performance in four categories: quality, resource use, EHR meaningful use, and clinical practice improvement activities.

Here too, ACA worked hard to assure that DCs were included in this vital new program. With quality reporting about to become the lynchpin of Medicare reimbursement, it is essential that chiropractic physicians are included.

Q: I’ve heard the ACA is working to achieve full‐scope in Medicare. Will this latest development put a halt to that effort?

A: All of this does not preclude ACA's goal of achieving full parity for chiropractic physicians in the Medicare program. Our work continues with Congress and the Obama administration to demonstrate that chiropractic physicians can serve Medicare patients in an efficacious and cost‐effective manner.

Q: How can I stay informed on developments regarding this legislation?

A: The ACA will be publishing updates regularly on our website, through various print and electronic distribution channels and through our social media network. Doctors of chiropractic who are not ACA members are advised to consider joining the Association to keep abreast of all the latest developments.

Q: Where can I go now, for the latest information on documentation and other information on Medicare?

A: DCs can learn more about Medicare and Medicare documentation requirements by visiting www.acatoday.org/Medicare


Source: ACA FAQ May 2015