In a recent ChiroCode Webinar, Attorney Jason Martin discussed the Patient Protection and Affordable Care Act (PPACA), as amended by the Health Care and Reconciliation Act of 2010. He introduced his material as some being “good news,” some being “no news,” and some being “bad news,” and he expressed the importance of understanding what’s coming down the pike for chiropactors and what to expect.
The law is huge, and Jason spent considerable time reviewing it (over 900 pages, in small print) in order to provide us his guidance. Some highlights are presented here; to view the complete webinar click on the link at the end of this article.
in regards to non-discimination, the law states: “A group health plan and a health insurance issurer offering group or individual health insurance shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law.” Attorney Martin told us that Senator Tom Harkin and the ACA fought hard to have this wording included. He believes that this particular section is a huge victory for chiropractors, and will hopefully level out the playing field with regards to the health insurance plans which are out there, and hopefully allow chiropractors to get paid for more of their services.
Jason cited an example in Pennsylvania where chiropractors are allowed by their scope of practice to perform manual therapy services, yet the particular health insurer chose not to reimburse them for this (the health plan would paid physical therapists for this service but not chiropractors). The Chiropractors were paid in error (due to a computer error), and over a year later, after the payer found the error, they requested a refund for all that money to be paid back from the chiroprators. There was not a whole lot that could be done because the plan was clear. Had the new law been enacted then, it could have been used in their favor.
There are limitations, and this doesn’t mean there will be open enrollment for chiropractors. Furthermore, plans may establish “varying reimbursement rates based on quality or performance measures;” however, they will now have to show that. This is very powerful language, and Senator Harkin needs to be thanked for that.
Compliance Programs: Compliance programs will required as a condition of participation under Medicare or Medicaid, and these compliance programs must contain core elements as required by the Secretary of HHS, in consultation with the OIG. This will happen at some point in the very near future. Jason believes this is a good thing, since it will help doctors to clean up any issues which can trigger post-payment reviews and audits.
Transparency and Program Integrity: An integrated data repository will be established and more authority given the OIG to obtain health records for the purpose of investigating fraud and abuse.
Overpayments: With PPACA, innocent overpayments can now become false claims upon failure to satisfy a refund obligation. If you do not return the money, you could be facing significant penalties and possible criminal action under the False Claims Act. PPACA forces chiropractors to be even more careful what they submit. If an overpayment is determined, it is EXTREMELY important to deal with it in the proper way, following the appeals process as laid out in the Social Security Act .
Anti-kickback Statute (AKS) PPACA changes the law to state that a person need not have actual knowledge of the AKS or specific intent to commit a violation
Timely Submission of Claims Claims must be submitted within one calendar year. Before, claims for the first 9 months of a calendar year could be submitted until Dec 31 of following year.
Jason Martin also discussed new points in law in regards to Medicare self-referral and disclosure protocol (Stark violations), suspension of payments, internal appeals, established processes, mandated external reviews, and increased funding for fraud initiatives.
This is a must-see webinar for all practices to wish to stay current and compliant with this massive new law. To view it, click here