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The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released a portfolio on chiropractic service vulnerabilities in the Medicare program.  The Centers for Medicare and Medicaid Services (CMS) Comprehensive Error Rate Testing (CERT) program found that chiropractic services had the highest improper payment rates among Medicare Part B services from 2010 to 2015.  Further, chiropractic services resulted in hundreds of millions of dollars in overpayments.  The OIG portfolio offers consolidated findings and issues identified through past OIG audits, evaluations, investigations, and legal actions.  It also provides recommendations from prior reports that were either not implemented or unsuccessfully implemented.  The portfolio is designed to assist CMS in understanding the need for effective controls and provide suggestions to prevent Medicare fraud, waste, and abuse related to chiropractic services.

Classifying Chiropractic Services

Chiropractic services are a form of alternative medicine focused on the diagnosis and treatment of musculoskeletal system disorders, particularly with the spine.  Medicare Part B covers chiropractic services, but does not cover chiropractic maintenance therapy, a common therapeutic procedure.  In order to receive payment, the chiropractic services must be reasonable and necessary, and provided by a qualified chiropractor.  Further, they must be adequately documented and involve active or corrective treatment for subluxation, or manual manipulation, of the spine.  If the chiropractic services become supportive rather than corrective, the treatment is considered maintenance therapy and will not be covered.  Maintenance therapy includes services that seek to prevent disease, promote health, prolong the quality of life, or prevent deterioration of a chronic condition.  CMS also contracts with Medicare administrative contractors (contractors) to make particular coverage decisions for services provided in each of their jurisdictions.

The CMS CERT program measures improper Medicare fee-for-service payments annually, and identified chiropractic services as having the highest improper payment rates among Medicare Part B services from fiscal years (FYs) 2010 to 2015.  Improper payment rates ranged from 43.9 percent to 54.1 percent, with estimated overpayments ranging from $257 million to $304 million.  Between calendar years (CYs) 2010 and 2015, Medicare paid a total of $2.9 billion for chiropractic services.  The program also determined that improper payments were made for services that were medically unnecessary, billed with the incorrect procedure code, not documented, or insufficiently documented.  The contractors’ independent review of the chiropractic service claims confirmed the findings of the CERT program.

In an effort to implement greater oversight of chiropractic services, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established two statutory changes.  Under MACRA, the HHS Secretary must implement a prior-authorization process for certain chiropractic services and develop educational and training programs to improve documentation of services.  Although CMS has taken steps to publicize the educational and training programs, it had not yet implemented the prior-authorization process as of July 2017.

Chiropractic Service Issues Identified by the OIG

The OIG reviewed its prior work on chiropractic services and identified the following issues:

  1. Medicare continued to make hundreds of millions in improper payments for chiropractic services.
  • In CY 2013, Medicare paid $34 million for chiropractic services that appeared to be for maintenance therapy.
  • In the same year, Medicare beneficiaries paid $91 million in coinsurance for medically unnecessary services.
  1. CMS has not established controls that fully prevent improper payments for chiropractic services.
  • CMS requires adding the Acute Treatment (AT) modifier to claims when providing treatment for subluxation. Claims without the AT modifier are considered claims for maintenance therapy, and are therefore denied.  However, including the AT modifier does not always indicate that the service provided was reasonable and necessary.
  • Additionally, CMS requires claims to include the initial treatment date, but this too has not ensured adequate supporting documentation of services furnished.
  • Provider education and medical record reviews have also failed to prevent improper payments. The OIG found that many chiropractors were unaware of Medicare requirements and resistant to education and changes in billing patterns.
  1. Chiropractic fraud is a concern.
  • An OIG investigation of 28 chiropractic fraud cases revealed that chiropractors attempted to defraud the Federal Government by submitting claims for services that were never provided, submitting claims for medically unnecessary services, offering incentives to patients to receive unnecessary services, providing services without a valid chiropractic license, falsifying patient records, and billing for chiropractic services but providing services not covered by Medicare.
  • These investigations resulted in incarcerations for 11 chiropractors and approximately $7.6 million in restitution and settlements.
  1. Establishing a medical review threshold for chiropractic services could save millions by reducing payments for medically unnecessary services without compromising beneficiary access to reasonable and necessary services.
  • CMS can set a threshold for the number of chiropractic services a beneficiary may receive per year and require medical review for services in excess of that threshold. Similarly, some private insurance companies provide coverage for chiropractic services.
  • Establishing a threshold would also save Medicare beneficiaries millions of dollars in coinsurance payments for medically unnecessary services.

OIG Recommendations

The OIG has made the following recommendations to CMS in previous OIG reports to encourage implementing and strengthening controls over billing for chiropractic services:

  • Implement and enforce policies to prevent future payments for chiropractic maintenance therapy;
  • Establish a more reliable control for identifying active treatment as it relates to the AT modifier;
  • Establish a reasonable number of chiropractic services that are necessary to treat subluxation and implement an edit to identify services in excess of that number;
  • Determine whether a limit for the number of chiropractic services that Medicare will reimburse is needed, and take appropriate action to put such a limit into effect;
  • Ensure that chiropractic services comply with Medicare coverage criteria; and
  • Improve education provided to chiropractors on Medicare coverage requirements and proper use of the AT modifier to ensure only medically necessary chiropractic services are billed to Medicare.

The OIG report is available at:

https://oig.hhs.gov/oas/reports/region9/91602042.pdf.

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