Summary of OIG Reports for Chiropractic

October 23rd, 2017 - Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP
Categories:   Chiropractic   Office of Inspector General (OIG)  
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The Office of the Inspector General was created to protect the integrity of the U.S. Department of Health and Human Services. They investigate fraud, waste, and abuse in HHS programs and make recommendations to various enforcement agencies. Every few years they investigate chiropractic services.  Here is a summary of the reports the OIG has released on chiropractic since 2005.  Click on the titles to access the complete reports at oig.hhs.gov.

2005: Chiropractic Services in the Medicare Program:  Payment Vulnerability Analysis

The report states that they found that:

  • Maintenance services were the most common type of noncovered chiropractic services that Medicare paid for in 2001
  • Supporting documentation for chiropractic services rarely met all Medicare Carriers Manual requirements
  • Lack of medical necessity is directly related to service volume
  • Carrier controls to prevent overutilization are inconsistent

They recommended that CMS:

  • Ensure that chiropractic services comply with Medicare coverage criteria
  • Require that its carriers educate chiropractors on Medicare Carriers Manual requirements for supporting documentation

2009: Inappropriate Payments for Chiropractic Services

The report states that they found that:

  • Medicare inappropriately paid $178 million for chiropractic claims in 2006, representing 47 percent of claims meeting our study criteria
  • Efforts to stop payments for maintenance therapy have been largely ineffective
  • Claims data lack initial visit dates for treatment episodes, hindering the identification of maintenance therapy
  • Chiropractors often do not comply with the Manual documentation requirements

They recommended that CMS:

  • Implement and enforce policies to prevent future payments for maintenance therapy
  • Review treatment episodes rather than individual chiropractic claims to strengthen the ability of the CERT to detect errors in chiropractic claims
  • Ensure that chiropractic claims are not paid unless documentation requirements are met. 
  • Take appropriate action regarding the undocumented, medically unnecessary, and miscoded claims identified in the sample

2013 Diep Chiropractic Wellness, Inc., Received Unallowable Medicare Payments for Chiropractic Services

In 2010 and 2011, Diep Chiropractic received Medicare Part B payments of $879,658 for
23,714 chiropractic services provided to Medicare beneficiaries.  The OIG reviewed a random sample of 100 chiropractic services.

The report states that they found that:

  • 93 of the 100 services were not allowable
  • An estimated $708,022 was therefore overpaid
  • Diep Chiropractic did not have adequate policies and procedures to ensure that chiropractic services billed to Medicare were medically necessary, correctly coded, and adequately documented

They recommended that Diep:

  • Refund $708,022 to the Federal Government
  • Establish adequate policies and procedures to ensure that chiropractic services billed to
    Medicare are medically necessary, correctly coded, and adequately documented

The report includes specific issues identified and Diep's response to the audit.  The findings were upheld.

2015 CMS Should Use Targeted Tactics to Curb Questionable and Inappropriate Payments for Chiropractic Services

The report states that they found that: 

  • In 2013, $76 million in Medicare payments for chiropractic services were questionable 
  • Almost half of the questionable payments were for claims suggestive of maintenance therapy
  • Just 2 percent of chiropractors were responsible for half of the questionable payments
    • These chiropractors provided more services to more beneficiaries compared to all other
      chiropractors and were located in high-fraud areas
    • Beneficiaries of these chiropractors were more likely to have had paid claims for physical and occupational therapy on the same day than were beneficiaries treated by other chiropractors, especially in high-fraud areas
    • Most of these chiropractors also had questionable payments in a prior year
  • In 2013, Medicare inappropriately paid $21 million for chiropractic services that lacked a primary diagnosis covered by Medicare

They recommended that CMS:

  • Establish a more reliable control for identifying active treatment, which would
    enable CMS to identify potential maintenance therapy
  • Develop and use measures to identify questionable payments for chiropractic services
  • Take appropriate action on the chiropractors with questionable payments
  • Collect overpayments based on inappropriately paid claims
  • Ensure that claims are paid only for Medicare-covered diagnoses

2015 Advanced Chiropractic Services Received Unallowable Medicare Payments for Chiropractic Services

IN 2011 and 2012, Advanced Chiropractic Services received Medicare Part B payments of $764,953 for 22,471 chiropractic services provided to Medicare beneficiaries. The OIG reviewed a sample of 105 chiropractic service line items.

The report states that they found that: 

  • The medical records did not support the medical necessity for any of the 105 sampled chiropractic service line items
  • An estimated $737,111 was therefore overpaid
  • ACS did not have adequate policies and procedures to ensure that the medical necessity of chiropractic services billed to Medicare was adequately documented in the medical records

They recommended that ACS:

  • Refund to the Federal Government $369,335 in estimated overpayments.
  • Work with Wisconsin Physicians Service Insurance Corporation (the Medicare administrative contractor that processed and paid the Medicare claims submitted by ACS) to return overpayments outside of the 3-year claims recovery period
  • Establish adequate policies and procedures to ensure that chiropractic services billed to Medicare are adequately documented in the medical records

The report includes specific issues identified and ACS's response to the audit.  The findings were upheld.

2015 Alleviate Wellness Center Received Unallowable Medicare Payments for Chiropractic Services

In 2012 and 2013, Alleviate Wellness Center received Medicare Part B payments of $498,764 for 16,343 chiropractic services provided to Medicare beneficiaries. The OIG reviewed a random sample of 100 chiropractic services.

The report states that they found that:

  • None of the 100 sampled chiropractic services were allowable in accordance with Medicare requirements
    • 56 services were medically unnecessary
    • 23 were insufficiently documented
    • 21 were not documented
  • An estimated $482,867 of the $498,764 paid to the Center for chiropractic services was unallowable for Medicare reimbursement
  • The Center did not have adequate policies and procedures to ensure that chiropractic services billed to Medicare were medically necessary and adequately documented

They recommend that the Center:

  • Refund $482,867 to the Federal Government
  • Establish adequate policies and procedures to ensure that chiropractic services billed to Medicare are medically necessary and adequately documented

2016 Hundreds of Millions in Medicare Payments for Chiropractic Services Did Not Comply with Medicare Requirements

The OIG selected 105 services from 2013 and divided them into three groups of 35 services each, based on the number of services:

  • Group 1 contained the 1st through 12th services
  • Group 2 contained the 13th through 30th services
  • Group 3 contained the 31st and subsequent services

Medicare paid $2,712 for these 105 services and used the sample results to estimate the amount paid for chiropractic services that did not comply with Medicare requirements.

They found that:

  • 94 of the 105 services from the sample were medically unnecessary, most from the 2nd an 3rd groups
  • An estimated $358.8 million, or approximately 82 percent, of the $438.1 million paid by Medicare for chiropractic services in 2013 was unallowable

They recommended that CMS:

  • Determine a reasonable number of chiropractic services that are necessary to actively treat spinal subluxation and implement a system edit to identify services for review in excess of that number
  • Determine whether there should be a limit for the number of chiropractic services that Medicare will reimburse; if so, take appropriate action to put that limit into effect, and implement a system edit to disallow services in excess of that limit
  • Improve education of chiropractors on Medicare coverage requirements for chiropractic services and the proper use of the AT modifier to ensure that only medically necessary chiropractic services are billed to Medicare
  • Specifically identify significant obstacles to developing a more reliable control for identifying maintenance therapy and work to establish such a control

2016 A Michigan Chiropractor Received Unallowable Medicare Payments for Chiropractic Services

In 2012 and 2013 a Michigan Chiropractor received Medicare Part B payments of $392,032 for 10,688 services provided to Medicare beneficiaries. The OIG reviewed a random sample of 100 chiropractic services.

The report states that they found that:

  • 92 of the 100 services were not allowable
  • The Michigan Chiropractor received estimated overpayments of at least $339,625
  • The clinic did not have adequate policies and procedures to ensure that the medical necessity of chiropractic services billed to Medicare was adequately documented in the medical records

They recommend that the Michigan Chiropractor:

  • Refund $339,625 to the Federal Government
  • Establish adequate policies and procedures to ensure that chiropractic services billed to Medicare are adequately documented in the medical records

2017 A Brooklyn Chiropractor Received Unallowable Medicare Payments for Chiropractic Services

This OIG review covered 18,187 claims for which the Brooklyn Chiropractor received Medicare reimbursement totaling $875,987 for chiropractic services provided during 2011 and 2012. They reviewed a random sample of 100 claims. 

The report states that they found that:

  • None of the 100 sample claims complied with Medicare requirements
  • The Brooklyn Chiropractor did not have adequate policies and procedures in place to ensure that chiropractic services billed to Medicare were medically necessary
  • The Brooklyn Chiropractor improperly received at least an estimated $672,805 in Medicare reimbursement for chiropractic services

They recommend that the Brooklyn Chiropractor:

  • Exercise reasonable diligence to investigate the potential overpayments totaling $672,805 and work with the Medicare Administrative Contractor to return any identified overpayments

The chiropractor's attorney used a consultant to dispute these findings, but they were upheld.

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