H.R. 2: The Medicare and CHIP Reauthorization Act of 2015
Permanent “Doc Fix” Heads to Presidents Desk, Congress Ushers in New Era of Value-Based Payment
Late last night, the United States Senate overwhelmingly passed legislation to permanently repeal the flawed Sustainable Growth Rate (SGR) formula, the method used by CMS to determine physician reimbursement in the Medicare program. In a bipartisan 92-8 vote, which followed a 392-37 vote in the U.S. House of Representatives at the end of March, the Senate sent House Resolution 2 – known as the “Medicare and CHIP Reauthorization Act of 2015” – to President Obama, who has indicated that he will sign the bill.
The Senate’s action last night prevented the implementation of a severe 21 percent cut that took place on April 1, 2015, and came after years of negotiations and 17 short-term “doc fixes” that staved off the major cuts scheduled under the SGR. Generally, the proposal would:
- Repeal the current SGR and institute a 0.5 percent payment increase for July-December 2015 and each year until 2019
- Shift Medicare reimbursement away from “fee-for-service” to a “pay-for-performance” system that incentivizes the use of alternative payment models and encourages providers to focus more on coordination and prevention, improving quality and reducing costs
- Streamline Medicare’s existing quality programs (PQRS, EHR Incentive Program, etc.) into one “value-based” performance program
Unfortunately, the bill also contained provisions specific to doctors of chiropractic: Section 514. Oversight of Medicare Coverage of Manual Manipulation of the Spine to Correct Subluxation. This section contains provisions providing for:
Medical Review of Spinal Subluxation Services
- The Secretary shall implement a process for the medical review of treatment by a chiropractor by means of manual manipulation of the spine to correct a subluxation of a Medicare beneficiary and apply such process to such services furnished on or after January 1, 2017, focusing on:
o Services furnished by a chiropractor whose pattern of billing is aberrant compared to peers, and
o Services furnished by a chiropractor who, in a prior period, has a services denial percentage in the 85th percentile or greater, taking into consideration the extent that service denials are overturned on appeal
- Prior Authorization Medical Review
o The Secretary shall use prior authorization medical review for services furnished by a chiropractor that are part of an episode of treatment that includes more than 12 services.
o An episode of treatment shall be determined by the underlying cause that justifies the need for services, such as a diagnosis code.
- Ending Prior Authorization Medical Review
o The Secretary shall end the application of prior authorization medical review if the Secretary determines that the chiropractor has a low denial rate under such prior authorization medical review.
o The Secretary may subsequently reapply prior authorization medical review to such chiropractor if the Secretary determines it to be appropriate and the chiropractor has, in the time period subsequent to the determination by the Secretary of a low denial rate with respect to the chiropractor, furnished services.
- Early Request for Prior Authorization Permitted
o Nothing in this subsection shall be construed to prevent such a chiropractor from requesting prior authorization for services that are to be furnished to an individual before the chiropractor furnishes the twelfth such service to such individual for an episode of treatment.
o The Secretary may use pre-payment review or post-payment review of services that are not subject to prior authorization medical review.
- The Secretary may implement the provisions of this subsection by interim final rule with comment period.
Improving Documentation of Services
- The Secretary of Health and Human Services shall, in consultation with stakeholders (including the American Chiropractic Association) and representatives of Medicare Administrative Contractors), develop educational and training programs to improve the ability of chiropractors to provide documentation to the Secretary of services in a manner that demonstrates that such services are reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
- The Secretary shall make the educational and training programs publicly available not later than January 1, 2016.
GAO Study and Report
- Study: The Comptroller General of the United States shall conduct a study on the effectiveness of the process for medical review of services furnished as part of a treatment by means of manual manipulation of the spine to correct a subluxation. Such study shall include an analysis of:
o Aggregate data on the number of individuals, chiropractors, and claims for services subject to such review; and
o The number of reviews conducted under such section; and
o The outcomes of such reviews.
- Report: Not later than four years after the date of enactment of this Act, the Comptroller General shall submit to Congress a report containing the results of the study conducted, including recommendations for such legislation and administrative action with respect to the process for medical review implemented as the Comptroller General determines appropriate.
A copy of Section 514 is attached.
Contact: Nicholas Strata