Medicare Compliance & Reimbursement

Capture chiropractic services accurately and benefit from new provisos thanks to MACRA.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) had yet to be passed into law when the Centers for Medicare and Medicaid Services (CMS) announced its intent to hold all Medicare claims and halt processing for the first two weeks of April. Eventually MACRA was signed into law on April 16, relegating the sustainable growth formula to history. 

Background: For years, the imposition of the SGR formula threatened to produce unsustainable reductions in Medicare payment levels for all Medicare providers, including chiropractors. It had no incentives for individual performance and made the payment amounts uncertain year after year.

“It was consistently becoming harder and harder to meet the bottom line when practices had a high percentage of Medicare patients,” observes Doreen Boivin, CPC, CCA, with Chiro Practice, Inc., in Saco, Maine. “The decrease in the amount reimbursed to the provider would have crippled the practice if it wasn’t monitored correctly.”

”I am pleased to see this flawed system, in place for nearly 20 years, eliminated,” said American Chiropractic Association (ACA) President Anthony Hamm, DC, in an ACA press release dated April 15, 2015. “Now chiropractic physicians don’t have to fear double digit cuts in reimbursement every year.”

Key features of the Act include:

• All physicians would receive a 0.5 percent per year increase in payments over the coming four years, until 2019.

• The bill implements, from 2019 onwards, a system of bonuses and penalties based on performance, an Alternative Payment Model (APM) or a Merit Based Incentive Payment System (MIPS).

• From 2019 to 2024, providers generating revenue from APM would get a 5 percent bonus, and those going by the MIPS would qualify for a portion of a $500 million pool allocated for providers with exceptional performance.

What’s In It For Chiropractors?

Here’s how chiropractors can benefit from the new law:

Documentation reeducation: As part of the ongoing federal effort to reduce Medicare claim error rates, the legislation requires HHS and ACA to develop an education program to help improve chiropractic documentation in consultation with Medicare Administrative Contractors (MACs). This needs to be implemented by Jan. 1, 2016.

“Documentation is key and educating the providers is a great benefit for all involved. It will definitely improve reimbursement issues where documentation is involved,” believes Boivin.

“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 Hamm in an ACA press release dated April 15, 2015. “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.”

DCs with higher denial rate: 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.

Sincerity pays: DCs with a good record of claims based on proper documentation and those who avail themselves of the education program will avoid pre-authorization requirements that non-compliant providers could eventually face.

Mint money with quality care: Another provision of interest to the profession is the Merit-Based Incentive Payment System (MIPS), following which one would qualify for a portion of $500 million pool allocated for providers with exceptional performance. Currently, there are three existing quality incentive programs including:

• Physician Quality Reporting System (PQRS)

• EHR Meaningful Use

• Value-Based Modifier.

Beginning in 2019, these will become one single program to ease reporting and shed the dispensable paperwork. So, get ready for adjustment in future payments based on your performance in four areas:

• Quality

• EHR Meaningful Use

• Resource use

• Clinical practice enhancement endeavors.

Good going for chiropractors: “ACA worked hard to assure that DCs were included in this vital new program,” Hamm stated in the April 15 press release.

“With quality reporting about to become the lynchpin of Medicare reimbursement, it is essential that chiropractic physicians are included.” He added that “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.”

Final takeaway: The struggle has been worth it. “Chiropractic physicians treat a myriad of symptoms when they adjust Medicare patients,” explains Boivin. She adds that, “they provide care otherwise not successful or even thought of in another physician practice. We need to continue to document with confidence and clarity to show the treatment is providing improvement in the health and functionality of the individual being treated.”

Read more: ACA report: www.acatoday.org/press_css.cfm?CID=5660. The entire bill: www.congress.gov/114/bills/hr2/BILLS-114hr2rds.pdf.