Small gains in healthcare legislation mean it’s time to get compliant, not complacent.
The healthcare legal landscape got a little confusing around mid-April.
First, the profession readied for the government’s double-digit (21 percent) cuts to Medicare provider payments. Then, at the eleventh hour, Congress passed a “permanent fix” to the former Sustainable Growth Rate (SGR) formula, so you no longer have to fret about this issue every spring. The fix even put a plan in place that would give doctors who participate in Medicare an annual payment increase of 0.5 percent for five years.
This is good, right?
Yes. But that affirmative comes with a big caveat. The legislation also contains a mandate for oversight of “manual manipulation of the spine to correct a subluxation.” Well, guess who performs that service? Indeed, the government is looking at you. A whopping nine pages of the new bill outline how that over- sight will take place for DCs. It includes a documentation education program for chiropractors along with the promise of even stiffer rules for this effort by Medicare (and the third-party payers who will inevitably follow suit).
These measures come as a reaction to the chiropractic profession as a whole, which is known for its miserable documentation efforts. The OIG estimates error rates as high as 90 to 94 percent.
Leaders at the ACA stepped up and saved chiropractors from even more severe discipline, like being removed from Medicare entirely. They argued that DCs can and will do better. They promised to spearhead an intensive documentation training blitz that will cover the U.S. and offer some insight into what Medicare is looking for. The government will be watching closely to see if you step up to the plate and improve.
The bill goes on to indicate that beginning January 1, 2017, chiropractors whose claim-denial rates are out of line with the rest of the profession will be subject to pre-authorization standards established by the Department of Health and Human Services (HHS). On the other hand, DCs with a good record of claims based on proper documentation, and those who avail themselves of the ACA’s education programs, can avoid those pre-authorization requirements.
Pre-authorization reviews will not only target unusual billing patterns but also documentation error rates coming in at 85 percent or higher. For example, anyone who got a Comparative Billing Report and is out of sync with local and national peers (i.e., most DCs in the country) will be on the hot seat.
Alternatively, if you can bring your error rate back down, it’s likely you’ll no longer be subject to prior review.
Don’t miss what’s important here: If your documentation is currently haphazard, incomplete or, as happens more often than we like to think, nonexistent, you have a chance to fix it before the pre-authorization requirements kick in. Clearly, the time to get educated is now.
Here are the important points to know if you fall into the group in question:
- Pre-authorization review requires determination prior to the service being furnished. In other words, you have to submit your treatment plan before you can actually adjust or otherwise treat your patient. Who wants that?
- Reviews will be required for more than 12 patient visits for any single episode of care, but you can ask for prior authorization before you hit that 12-visit cap.
- Prior authorization can be obtained for multiple services.
- Payments will be denied without prior authorization—unless Medicare fails to respond within 14 days.
- Pre- and post-payment reviews can be used by Medicare Administrative Contractors (MACs) or any other contractor except Recovery Audit Contractors (RACs)—even when pre-authorization doesn’t apply.
Although your Medicare payments may be higher with the modified legislation, government scrutiny will rise to the occasion. All chiropractors whose documentation or billing patterns are less than stellar will be subject to pre-payment authorization review starting in 2017. That sounds like a long way off, but with ICD-10 occupying most offices for the rest of the year, this is no time to get complacent.
Getting a jump on Medicare documentation training and education now can help you avoid huge headaches, hassles, and real risk down the line.
While most doctors assume their documentation is mostly fine, statistics don’t support that assumption. Make sure your documentation is impeccable. And then, by all means, let the good times roll.
Kathy Mills Chang, MCS-P, CCPC, is a certified medical compliance specialist (MCS-P) and, since 1983, has been providing chiropractors with reimbursement and compliance training, advice, and tools to improve the financial performance of their practices since 1983. She leads a team of 16 at KMC University and is known as one of the profession’s foremost experts on Medicare. She or any of her team members can be reached at 855-832-6562, info@kmcuniversity.com, or through kmcuniversity.com.
