SGR Repealed!
Written by Editor   
Tuesday, April 14, 2015 10:01 PM

The sustainable growth rate (SGR) formula is no more. Thanks to new legislation adopted Tuesday April 14.  

In a historic move late Tuesday, the Senate voted 92-8 to permanently repeal the sustainable growth rate (SGR) formula for physician reimbursement under Medicare.  The measure now heads to President Obama, who has said he will sign it.  Medicare patients and their doctors no longer will be threatened by the flawed payment formula that left the Medicare program unstable and threatened access to care.

The U.S. Senate Tuesday evening followed the U.S. House of Representatives’ lead and passed a bill to immediately repeal the SGR formula.

The Medicare Access and CHIP Reauthorization Act was adopted by a vote of 92 to 8 on the eve a 21 percent cut to Medicare payments was set to take place. The vote came a little after 9:30 p.m. Eastern time following several attempts to amend the measure, all of which failed.  

The bill provides positive annual payment updates of 0.5 percent, starting July 1 and lasting through 2019. Claims that were held for the first half of April will be processed and paid at the rates that were in place before the 21 percent cut was scheduled to take effect.

In addition to addressing Medicare payment, the legislation outlines several provisions including:

  • A provision directing 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) and implemented by Jan. 1, 2016. This is part of an ongoing federal effort to reduce Medicare claim error rates.

Under the 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.

"This provision will provide ACA the opportunity to educate those who are not compliant with clinical decision-making and documentation of the Medicare patient," explained Dr. Hamm. "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."

  • 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.

"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," added Dr. Hamm. "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."

  • Protections are included so that medical liability cases cannot use Medicare quality program standards and measures as a standard or duty of care.

  • Incentive payments will be available for physicians who participate in alternative payment models and meet certain thresholds.

  • Technical support will be provided to help smaller practices participate in alternative payment models or the new fee-for-service incentive program.

While the bill supports physicians who choose to adopt new payment and delivery models, it also retains Medicare’s fee-for-service model. Participation in new models is entirely voluntary.  The legislation takes an important first step by eliminating the SGR formula.

The votes in the House and Senate came after years of negotiations to get rid of the much-maligned formula, in which Medicare physician reimbursements were linked to increases in the gross domestic product; the formula invariably resulted in payment cuts for physicians. The cuts were staved off each time by a series of payment "patches" passed by Congress.


American Chiropractic Association News Release April 15, 2015