Protecting the Integrity of Medicare Act

Protecting the Integrity of Medicare Act

In April 2015, Congress passed, and the president signed, the Protecting the Integrity of Medicare Act (PIMA). This sweeping legislation was designed to repeal the flawed Sustainable Growth Rate (SGR) formula used to determine provider reimbursement levels under the federal Medicare program. Congress was repeatedly forced to enact a series of temporary postponements to avoid the full brunt of the payment reductions from taking place.   

ACA worked with congressional members and staff to ensure the legislation was balanced and that doctors or chiropractic (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.

Medicare Error Rate Reduction

PIMA 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.  

Important Provisions

Payment Increase

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 value‐based 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. Repealing the SGR system means that chiropractic physicians will no longer fear double digit cuts in reimbursement every year.

Education Initiative

PIMA also 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). This provision will provide the ACA the opportunity to create education resources for those who are not compliant with clinical decision‐making 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.

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

Pre-Authorization Standards

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

Merit‐Based Incentive Payment System

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.

What's Next

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 ACA to make cooperating state associations full partners working with us to ensure that that Medicare claims error rates are reduced significantly.  

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.   

ACA is ultimately focused on 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.  

Questions? Contact ACA.