Questions Remain

The Department of Health and Human Services’ Office of Inspector General (OIG) released a report this past June titled, Chiropractic Services in the Medicare Program: Payment Vulnerability Analysis. The report states that Medicare has allowed payment for chiropractic services that are “medically unnecessary, undocumented, and noncovered,” and that chiropractic services represent “a significant vulnerability for the Medicare program.” (The report can be downloaded at http://oig.hhs.gov/oei/reports/oei-09-02-00530.pdf.)

The report is based on data collected in 2001. In 1998, the OIG released a report titled, Chiropractic Care: Controls Used by Medicare, Medicaid, and Other Payers. That report stated that approximately 24% of Medicare chiropractic claims were for noncovered maintenance treatments. After that report was released, the American Chiropractic Association (ACA) expressed concerns with the report and met with the OIG in 2001. As a result of the meeting, the OIG launched another inspection concerning chiropractic maintenance treatments. The methodology for this inspection included peer medical review of a random sample of Medicare claims, and the results are the product of this new report.

The ACA released a statement criticizing the June 2005 OIG report on several grounds. The report’s findings reflect a universal problem in physician documentation and do not represent a concerted effort by DCs to overbill the government for nonreimbursable Medicare services, the ACA wrote. The OIG report, according to the ACA statement, “provides only passing reference to a program initiated in October 2004 that specifically addresses the very problems mentioned in this report.”

The October 2004 program that the ACA mentions is a requirement by Centers for Medicare & Medicaid Services (CMS) that chiropractors use the “AT” modifier to indicate that a service is not maintenance. Only claims to which this modifier is attached are payable.

Tom Daly, the ACA’s legal counsel, told me that the ACA has a new documentation manual to address this problem. This wasn’t included in OIG’s report.

Unfortunately, the OIG wasn’t willing to talk to me about this matter. The only response they gave me was, “The report speaks for itself.”

Another of the report’s findings is that as chiropractic care extends beyond 12 treatments in a year, “It becomes increasingly likely that individual services are medically unnecessary.”

But many patients rely on maintenance care to feel their best. Unfortunately, the medical profession has a different agenda. Agreeing with me is Tim Maggs, DC, and CP editorial advisory board member. “In a world that relies on surgery, steroids, and anti-inflammatory drugs, it doesn't make sense that anyone could question the benefit of maintenance chiropractic care,” he said.

It’s good to see that the ACA is on top of this matter. Daly said that the ACA’s Board of Governors would appoint a special committee to review the report and its methodology. The task force will make recommendations to the ACA’s House of Delegates, which will meet in September. Stay tuned for further news on obtaining answers to the questions this report raises. In the meantime, I look forward to hearing your opinion on the matter. CP

Daryl Lubinsky
dlubinsky@ascendmedia.com