by Ray Foxworth, D.C., FICC, MCS-P

President & Founder, ChiroHealthUSA

For years, we have heard that the Office of Inspector General (OIG) is cracking down on healthcare fraud, waste, and abuse. The OIG began issuing reports with concerns about overpayments for chiropractic services as early as 2001 and as recently as 2018. In 2018, the OIG stated that chiropractic had the highest rate of improper payments (2010 through 2015) ranging from 43.9% to 54.1% compared with 9.9% to 12.9% for all other Part B services. (OIG, 2019)

It surprises me the number of providers that continue to look for “workarounds” for Medicare policies in their office. The bottom line is that Medicare and the OIG expect you, as a provider who treats Medicare patients, to know the law. And you can’t just interpret the rules to fit your desired office policies and procedures. As one provider recently learned, it can be costly when you fail to follow the rules.

On August 30, 2019, the OIG published a report on the latest chiropractic office that was audited and ultimately fined them $317,038 for just $1,680 in services billed to Medicare. (Office of Public Affairs OIG, 2019)

Why were they audited?

In calendar years (CYs) 2014 and 2015, Medicare allowed payments of approximately $1.3 billion for chiropractic services provided to Medicare beneficiaries nationwide. Previous OIG reviews found that Medicare inappropriately paid for chiropractic services that were medically unnecessary, incorrectly coded, or undocumented. This Florida chiropractic office was selected from an analysis that indicated they were among the top five chiropractors billing for the three covered services to Medicare in their state.

What did the OIG review in this audit?

The objective of this audit was to determine whether chiropractic services billed by this practice were allowable in accordance with Medicare requirements. For CYs 2014 and 2015, this chiropractic office received payments for 22,967 chiropractic services to Medicare patients. 619 chiropractic services were excluded from the audit due to prior reviews from other entities. Out of the remaining 22,348 services, totaling $704,246 in Medicare payments, the OIG selected 100 services using a simple random sample.

What were the results?

Of the 100 sampled chiropractic services in the OIG sample, 46 were allowable in accordance with Medicare requirements. The remaining 54 services were not allowable for the following reasons:

  1. 42 chiropractic services were found to be medically unnecessary.
    • Subluxation of the spine was not present or not treated with manual manipulation or both. (7 services)
    • Manual manipulation of the spinal subluxation was maintenance therapy or was not appropriate for the treatment of the patient’s condition or both. (26 services)
    • Manual manipulation of the spinal subluxation would not be expected to result in improvement within a reasonable and generally predictable period. (9 services)
  2. 11 chiropractic services were found to be insufficiently documented.
    • Insufficient documentation for the initial chiropractic visit. (4 services)
    • Insufficient documentation for both the initial and subsequent chiropractic visits. (7 services)
  3. 1 chiropractic service was coded incorrectly.
    • The claim for this service was billed with a CPT code related to the treatment of more spinal regions than the patient’s medical record supported.
  4. It was determined during the audit that the clinic did not have policies and procedures in place to ensure that services billed to Medicare were medically necessary, adequately documented, and coded correctly.

The clinic received $1,680 in unallowable payments for the 54 services not allowable from the sample. The OIG estimated that the clinic received unallowable payments of at least $317,038 in 2014 and 2015. To calculate the unallowable amount for the service, the OIG uses the difference between the amount paid to the provider under CPT code 98941 and the amount that should have been paid to the provider under CPT code 98940. The paid amount is equal to the allowed amount, less the beneficiary share (i.e., deductibles and coinsurance).

This audit and others are proof that Medicare is stepping up its investigations and is continuing to develop the means to analyze our claims. Because of this increased scrutiny, chiropractic claims are going to be reviewed in more detail. Thinking that it won’t affect you is no longer an option. Now is the time to be sure that your documentation, coding, and billing procedures are in compliance with the rules and regulations.

Not sure where your practice stands? In less than five minutes, you can answer 8 simple questions and find out exactly which aspects of your financial policies may have you inadvertently exposed to potential complaints, audits, fines, and penalties.

You will receive an email with:

  • A personalized confidential report on your greatest areas of risk based on YOUR responses.
  • A specific grade assessment of your current vulnerabilities.
  • A clear explanation of WHY you may be at risk.
  • Detailed steps you can take IMMEDIATELY to minimize your risks.

Request your Risk Assessment Score by October 10, 2019 and win one of ten copies of the Medicare Playbook for Chiropractic, authored by Dr. Scott Munsterman, Dr. Tim Wakefield, and healthcare attorney and chiropractor, Dr. Steve Conway. By applying the very simple and understandable procedures outlined in this comprehensive manual, Chiropractors will have greater success in managing documentation standards per Medicare policy and the Medicare payment system.

Click here to request your Risk Assessment Score (RAS) today!

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