Medicare: Status of HHS's Implementation of Required Prior Authorization Medical Reviews and Provider Education for Chiropractic Services

What GAO Found

Chiropractic services focus on the diagnosis and treatment of disorders of the musculoskeletal system, especially the spine, and Medicare pays for certain treatments involving manual spinal manipulations. Chiropractic services have a relatively high rate of improper payments (about 41.7 percent or $235 million estimated in fiscal year 2017, according to data from the Department of Health and Human Services [HHS]). This rate has declined in recent years and the amount represents less than 1 percent of the estimated $36.2 billion in Medicare fee-for-service improper payments in fiscal year 2017. To reduce improper payments for other items and services, the Centers for Medicare & Medicaid Services (CMS)--an agency within HHS--has used prior authorization medical reviews, in which prior to furnishing an item or service to a beneficiary and submitting a claim to Medicare for payment, a health care provider demonstrates compliance with Medicare coverage and payment rules.

As of June 2018, CMS had not implemented a process for the prior authorization medical reviews for chiropractic services provided on or after January 1, 2017, as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS has indicated that it will issue a notice of proposed rulemaking in December 2018 to begin to establish the prior authorization process.

CMS has conducted activities and developed materials in response to MACRA's other requirement that educational and training programs be made available by January 1, 2016, to improve providers' documentation of chiropractic services. CMS held a forum in September 2015 to request input from the chiropractic stakeholder community on specific training needs and published a series of three educational articles for chiropractors that identify Medicare's rules for coverage and medical record documentation for chiropractic services. In response to stakeholders' requests for educational materials, CMS also published a video on its YouTube channel on December 23, 2015, that answers questions about documentation requirements for chiropractic services. As of the issuance of this report, the educational articles and video are available on CMS's website.

GAO provided a draft of this correspondence to HHS for review and comment. The department did not have any comments.

Why GAO Did This Study

In fiscal year 2016, Medicare spent approximately $540 million on chiropractic services. This represents less than 1 percent of the nearly $700 billion Medicare reportedly spent for health services for its 57 million elderly and disabled beneficiaries. MACRA includes provisions requiring HHS to implement a prior authorization medical review process for chiropractic services and to consult with stakeholders and CMS contractors to develop educational and training programs to improve the ability of chiropractors to provide proper documentation. MACRA also includes provisions for GAO to review the effectiveness of HHS's medical review process.

This report describes the status of HHS's efforts to implement prior authorization medical reviews and develop materials for educational and training programs for chiropractic services, as required by MACRA. GAO reviewed CMS guidance, relevant legislation, HHS Office of Inspector General (OIG) publications, and training and educational materials developed by CMS. GAO also interviewed CMS and HHS OIG officials and professionals from the American Chiropractic Association to obtain information on their involvement in developing these materials.

For more information, contact Jessica Farb at 202-512-7114 or farbj@gao.gov.