Georgia Chiropractic Association Meeting May 21, 2016 Thom R. Mitchell, MD Senior Contractor Medical Director Proprietary Information DO NOT DISTRIBUTE

Disclaimer This resource is not a legal document. This presentation was prepared as a tool to assist providers. This presentation was current at the time it was created. Although every effort has been made to assure accurate information, responsibility for correct claim submission lies with the provider of the services. Reproduction of this material for profit is prohibited. Proprietary Information DO NOT DISTRIBUTE Slide 2

Agenda Proprietary Information DO NOT DISTRIBUTE Slide 3 What is Medicare? Role of the Medicare Administrative Contractor Stewards of the Medicare Trust Fund How this came to be Comprehensive Error Rate Testing Program CERT Results

Origin of Medicare Proprietary Information DO NOT DISTRIBUTE Slide 4 Wilbur Mills ‘three-layer cake’ started with LBJ’s Medicare proposal (Part A), later added physician and other outpatient services (Part B), and Medicaid. 7/30/1965 LBJ signed HR 6675 in Independence, MO and Medicare and Medicaid were enacted as TitleXVIII and TitleXIX of the Social Security Act 1966 Medicare was implemented and more than 19 million individuals enrolled by July 1. Payments to health care physicians and providers conditional on desegregation (spurred racial integration)

Medicare Milestones 1972 President Nixon extends Medicare eligibility to disabled individuals less than 65 years old and ESRD Doctors of Chiropractic defined as “physicians” and Chiropractic services added 1977 Part C, Medicare Choice MA established 2003 President George W. Bush signs the Medicare Modernization Act which establishes Medicare Part D January 1, 2006 Part D goes into effect 2010 President Barack Obama signs Patient Protection and Affordable Care Act mandates beneficiaries receive preventative care services and health screenings free of charge and reduces Part D out of pocket expenses Proprietary Information DO NOT DISTRIBUTE Slide 5

Medicare Medicare Part A – Deductable Medicare Part A Trust Fund financed through a payroll tax is estimated to become insolvent in 2030 Medicare Part B – Deductable – Monthly premium Medicare Part B is financed largely through general revenues and thus cannot become insolvent. (41% of Medicare cost from general revenue, will increase to 45% in 15 years) Proprietary Information DO NOT DISTRIBUTE Slide 6

Social Security Act Sec [42 U.S.C. 1395y] (a) Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services— (1)(A) which, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, Proprietary Information DO NOT DISTRIBUTE Slide 7

MACRA Medicare Access and CHIP Reauthorization Act of 2015 – Section 514 Oversight of Medicare coverage of manual manipulation of the spine to correct subluxation – Establish Medical Review of Chiropractic Services focusing on practitioners with a “pattern of billing aberrant compared to peers” and in a previous period had service denial percentages in the 85 th percentile or greater-Implementation 1/1/2017 – Prior Authorization for an episode of treatment that includes more than 12 services for practitioners described above – Practitioner may request prior authorization for greater than 12 services – Secretary of HHS, ACA and the MACs develop educational and training programs to improve the ability of chiropractors to provide documentation demonstrating services are reasonable and necessary- Implementation 1/1/2106 Proprietary Information DO NOT DISTRIBUTE Slide 8

Medicare Contracting MAC (Medicare Administrative Contractor) DMEMAC (Durable Medical Equip MAC) HH&H (Home Health and Hospice) CERT (Comprehensive Error Rate Testing) RA (Recovery Auditors) ZPIC (Zone Program Integrity Contractor) QIC (Qualified Independent Contractor) QIO (Quality Improvement Organization) – Beneficiary and Family Centered Care – Quality Innovation Network SMRC (Supplemental Medical Review Contractor) Proprietary Information DO NOT DISTRIBUTE Slide 9

MAC A/B Jurisdiction Map Proprietary Information DO NOT DISTRIBUTE Slide 10 JF Noridian JF Noridian J5 WPS J5 WPS JE Noridian JE Noridian J6 NGS J6 NGS J8 WPS J8 WPS J15 CGS J15 CGS JH Novitas JH Novitas JJ Cahaba JJ Cahaba JN FCSO JN FCSO J11 Palmetto J11 Palmetto JL Novitas JL Novitas JK NGS JK NGS JF

Medicare Administrative Contractors Role of the MAC – Statement of Work Definition of the Chiropractic Benefit – Medicare Benefit Policy Manual (Chapter 15, section 30.5 & 240) – Medicare Claims Processing Manual (Chapter 12, section 220) Stewards of the Medicare Trust Fund – Program Integrity Manual New provider prepay monitoring program (compared to peers) – Additional Documentation Request (ADR) Targeted prepay review – Additional Documentation Request (ADR) Proprietary Information DO NOT DISTRIBUTE Slide 11

American Chiropractic Association ACA/Medicare Administrate Contractor Collaborative Outreach Forum Lead by the ACA Medicare Committee Chair and Vice-chair February 2015 Develop educational resources to achieve the goals of reduced error rates and increased Center for Medicare and Medicaid Services (CMS)compliance. Proprietary Information DO NOT DISTRIBUTE Slide 12

Comprehensive Error Rate Testing Program Established by CMS to monitor the accuracy of claim payment in the Medicare Fee-For-Service program Sampling methodology, randomly selected claims based on services with the highest historical improper payments Communication with the provider all has CMS letterhead (contractors are invisible) Preferred method of record exchange is fax (mail is secondary) Reimbursement recouped by the MAC Same appeal rights as Medicare Proprietary Information DO NOT DISTRIBUTE Slide 13

Comprehensive Error Rate Testing Program CERT Documentation Contractor – CERT Review Contractor –Determines error rate for the MAC CERT Statistical Contractor CERT Report Website Contractor –Maintains Proprietary Information DO NOT DISTRIBUTE Slide 14

Comprehensive Error Rate Testing Program Proprietary Information DO NOT DISTRIBUTE Slide 15 Claims Type Paid Claims Error Rate (for reviewed claims) 95% Confidence Interval Number of sampled claims (Completely Reviewed) Error Rate (partial imputation)* Overall J1010.6%8.1% %2, % Part B11.0%6.1% %1, % Overall Part A10.4%7.6% %1, % Table 1.1: Showing Error Rate for 2015 by “Claims Type”

Comprehensive Error Rate Testing Program Proprietary Information DO NOT DISTRIBUTE Slide

Comprehensive Error Rate Testing Program Proprietary Information DO NOT DISTRIBUTE Slide projected

Comprehensive Error Rate Testing Program 2015 What are the errors? – 65% No chiropractic treatment plan documented to support a plan of care – No records received – Documentation does not support an acute process – Initial evaluation not included with the claim – No or illegible signature 2016 What are the errors? – 100% No chiropractic treatment plan documented to support a plan of care – Missing copy of initial evaluation – Documentation did not support manipulation of 5 regions – No or illegible siignature Proprietary Information DO NOT DISTRIBUTE Slide 18

Additional Documentation Requests Proprietary Information DO NOT DISTRIBUTE Slide 19

Comprehensive Error Rate Testing Program Proprietary Information DO NOT DISTRIBUTE Slide 20

and Website Contacts REFERENCES – Contract Medical Directors – Final LCDs WEBSITES LCDs

CahabaGBA QUESTIONS? Proprietary Information DO NOT DISTRIBUTE Slide 22