Consistently over the years the Office of Inspector General (OIG) has targeted chiropractic services for audits. In fact, chiropractic services appear annually on the OIG’s workplan agenda. In September 2015, the OIG issued a report recommending that the Centers for Medicare & Medicaid Services’ (CMS) establish better controls and measures to prevent questionable payments, collect overpayments based on inappropriately paid claims and ensure that claims are paid only for Medicare-covered diagnoses.
According to the OIG, CMS’ Comprehensive Error Rate Testing program shows that chiropractic services have the highest rate of improper payments among Part B services. Furthermore, from 2010 to 2014, the improper payment rate for chiropractic services increased from 43.9 to 54.1 percent.
Medicare limits coverage of chiropractic services to manual manipulation treatments to treat subluxation of the spine, which is the dislocation of one or more spinal bones. Such services to improve function (“active treatment”) differ from “maintenance therapy,” which is not covered by Medicare. According to the Medicare Benefit Policy Manual, maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. The policy manual provides that when further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.
OIG reports from 2005 and 2009 found that up to 47 percent of paid chiropractic claims were for maintenance therapy. Both reports found that when chiropractic care extends beyond 12 treatments in a year services are “increasingly likely” to be medically unnecessary. Failure to comply with Medicare documentation requirements was also a common element in OIG’s review of claims for chiropractic services.
The OIG’s report found that in 2013, $76 million in Medicare payments for chiropractic services were questionable. The agency further found that nearly half of the questionable payments were for claims suggestive of maintenance therapy. In addition, the OIG found that just 2 percent of chiropractors were responsible for half of the questionable payments. Most of these chiropractors also had questionable payments in prior years. The agency also reported that in 2013, Medicare inappropriately paid $21 million for chiropractic services that lacked a primary diagnosis covered by Medicare.
While CMS does not limit the number of chiropractic services that a beneficiary may receive, certain MACs have issued LCDs that limit the number of chiropractic services per beneficiary per year or require medical review for services that exceed a certain threshold. The NGS local coverage determination, for example, have recently been updated to state that “utilization exceeding two courses of chiropractic treatment may be subject to Medical Review.” Novitas imposes a limit of up to 12 chiropractic manipulations per calendar month and 30 chiropractic manipulation services per beneficiary per calendar year.
If you have questions about the recent OIG report, OIG chiropractic audits, or have other health law question please contact our office.