OIG and Chiropractors: The Findings

We have covered what the OIG was looking into chiropractors. Now lets peak at what they have found…

In 2013, $76 million of the Medicare payments for chiropractic services were questionable Of the $502 million that Medicare paid in 2013 for chiropractic services, $76.1 million was for claims that were questionable based on our four measures of questionable payment. Payments for these claims represent 15 percent of the Medicare payments for chiropractic services in 2013. Treatment suggestive of maintenance therapy was the driver of questionable payments In total, 16 percent of chiropractors (7,191) paid by Medicare in 2013 received questionable payments for chiropractic services. Almost half of these payments were for claims suggestive of maintenance therapy, which we identified through high average numbers of claims per beneficiary per chiropractor. Medicare does not cover maintenance therapy. Table 3 provides detail on our measures that identified questionable payments. The 1,787 chiropractors (4 percent) who had questionable payments for claims suggestive of maintenance therapy provided an average of 25 services per beneficiary during 2013. In contrast, all other chiropractors provided an average of 8 services per beneficiary during 2013. Although we are unable to determine when a beneficiary’s course of treatment began, the volume of services that these chiropractors provided to their beneficiaries suggests that the treatment was maintenance.22 Table 4 shows noteworthy examples of chiropractors with questionable payments for treatment suggestive of maintenance therapy. Lastly, the use of the AT modifier to ensure that payments are made only for active treatment is not effective. Every claim that we identified as being suggestive of maintenance therapy included the AT modifier, raising questions about its effectiveness as a control to ensure that Medicare pays only for active treatment. Prior OIG work found that CMS’s requirement to use the AT modifier to indicate active treatment merely resulted in an increase in the use of the AT modifier, rather than in reduced payments for maintenance therapy.23 Moreover, in 2013, 96 percent of all claims for chiropractic services that were submitted to Medicare included the AT modifier.24 About $47 million in questionable payments was related to potential beneficiary sharing, upcoding, and unlikely number of services per day Potential sharing of beneficiaries. In 2013, Medicare paid $25.7 million to chiropractors who shared 52.5 percent or more of the beneficiaries they treated with other chiropractors. These 4,216 chiropractors represent 9 percent of the chiropractors paid by Medicare in 2013. In contrast, chiropractors who did not have questionable payments for beneficiary sharing had an average of 14 percent of their beneficiaries who received services from other chiropractors. It is possible that beneficiaries chose to receive services from multiple chiropractors. However, when high percentages of beneficiaries receive services from multiple chiropractors, this has implications for the continuity of the beneficiaries’ care. High percentages of beneficiaries who are shared among chiropractors also may be related to fraud schemes, such as medical identity theft or kickback arrangements. Potentially upcoded claims. Medicare paid $21.3 million to chiropractors whose payments had high average physician work relative value units (RVUs), which reflect the relative time and skill associated with furnishing services under the Medicare Physician Fee Schedule.25 By analyzing the work RVUs, we identified 1,450 chiropractors, or 3 percent, as outliers who were paid for chiropractic services at higher-levels than other chiropractors were. Of these chiropractors, more than half had all of their Medicare payments for the highest level chiropractic CPT code—98942— which is an adjustment of all five regions of the spine. In contrast, only a fifth of chiropractors paid by Medicare in 2013 were paid for this CPT code, and just 10 percent of the Medicare payments for chiropractic services were for this code. Although some chiropractors may specialize in complex conditions, previous OIG work found that almost half of the claims for chiropractic services with CPT code 98942 were upcoded.26 Unlikely number of services per day. Medicare paid $768,964 to 16 chiropractors for days on which their paid chiropractic services totaled 16 hours or more. However, 81 percent of the payments for this measure went to two chiropractors (see Table 5). This raises questions regarding the quality of patient care and, perhaps, whether these services were even rendered by the chiropractor.

Two percent of chiropractors were responsible for half of the questionable payments.

In 2013, 962 ofthe 45,490 chiropractors paid by Medicare received $38 million of the $76 million in questionable payments (see Figure 2). These 962 chiropractors (hereinafter, chiropractors with high questionable payments) received 9 percent ($43.6 million) of all Medicare payments for chiropractic services in 2013. We identified 87 percent of their payments as questionable. Source: OIG analysis of data from 2013 Part B claims for chiropractic services paid for by Medicare. * A total of 45,490 chiropractors were paid by Medicare in 2013. The total number of chiropractors with questionable payments in 2013 was 7, 191. Chiropractors with high questionable payments provided more services to more beneficiaries compared to all other chiropractors On average, chiropractors with high questionable payments provided chiropractic services to twice the number of beneficiaries compared to all other chiropractors (see Table 6). In addition, the chiropractors with high questionable payments had about 4 times the number of paid chiropractic claims compared to all other chiropractors. Accordingly, the Medicare payments to chiropractors with high questionable payments were also 4 times higher than payments to other chiropractors. Questionable and Inappropriate Payments for Chiropractic Services (OEl-01-14-00200) 11

Chiropractors with high questionable payments provided more services to more beneficiaries compared to all other chiropractors
On average, chiropractors with high questionable payments provided chiropractic services to twice the number of beneficiaries compared to all other chiropractors (see Table 6). In addition, the chiropractors with high questionable payments had about 4 times the number of paid chiropractic claims compared to all other chiropractors. Accordingly, the Medicare payments to chiropractors with high questionable payments were also 4 times higher than payments to other chiropractors.
Half of these chiropractors’ questionable payments were for treatments suggestive of maintenance therapy
In addition to being high-volume providers, chiropractors with high questionable payments had more payments for claims suggestive of maintenance therapy. For the chiropractors with high questionable payments, 53 percent of their claims were suggestive of maintenance therapy. In contrast, just 3 percent of the claims for all other chiropractors paid by Medicare in 2013 were suggestive of maintenance therapy.
Over a quarter of these chiropractors’ claims were for the highest intensity chiropractic service
Medicare paid the chiropractors with high questionable payments substantially more for treatments to five regions of the spine, CPT code 98942. Twenty-eight percent of paid services provided by chiropractors with high questionable payments were for 98942. In contrast, only 5 percent of paid services provided by all other chiropractors were for this CPT code. Finally, 30 percent of the chiropractors with high questionable payments received 95 percent or more of their Medicare payments for CPT code 98942, yet just 3 percent of all other chiropractors received 95 percent or more of their Medicare payments for this code.

Many chiropractors with high questionable payments shared certain characteristics

Chiropractors with high questionable payments were located in certain States as well as in high-fraud areas
Fifty-nine percent of the chiropractors with high questionable payments were concentrated in seven States: California, Michigan, Illinois, New York, Kansas, Florida, and New Jersey. Each of these States had more than 50 chiropractors with high questionable payments. In total, these chiropractors received about a third ($23.8 million) of all questionable payments in 2013. The remaining 41 percent of chiropractors with high questionable payments were located in 38 other States. In addition, most of the counties that had 10 or more chiropractors with high questionable payments are located in Medicare Fraud Strike Force (Strike Force) areas. The Strike Force operates in locations considered to be “hot spots” for Medicare fraud and targets suspicious billing patterns as well as emerging schemes that migrate from one community to another.27,28 The chiropractors in the 11 Strike Force counties included in Table 7 represented nearly one quarter of the chiropractors with high questionable payments, and they collectively received $9.5 million in questionable payments.

Beneficiaries of chiropractors with high questionable payments were more likely to have paid claims for physical and occupational therapy on the same day, especially in high-fraud areas

Thirteen percent of beneficiaries who had a paid claim for a service from a chiropractor with high questionable payments also had one or more paid claims for physical/occupational therapy (hereinafter, therapy services) on the same day. In contrast, only 4 percent of beneficiaries who had services from other chiropractors had therapy services on the same day. Moreover, beneficiaries with paid claims from a chiropractor with high questionable payments had an average of three times the dollar amount of therapy services on the same day than the other beneficiaries. Although it is plausible that some beneficiaries had same-day therapy independent of the chiropractic services, the concentration of providers of both types of services—as well as their locations and amount of therapy services provided—suggests otherwise. Sixty percent of chiropractors with high questionable payments had two or more beneficiaries who received same-day therapy services. In contrast, just 24 percent of chiropractors without high questionable payments had two or more beneficiaries who received same-day therapy services. In addition, the payments to therapists appear to be concentrated in amount and location. The average payment to therapists for beneficiaries who received same-day services from chiropractors with high questionable payments was five times higher than the average payment to therapists for other beneficiaries. Moreover, 90 percent of the $10.6 million in payments for same-day therapy services was paid to therapists in Strike Force areas, and Medicare paid just over half of this amount to only 16 therapists.

Most chiropractors with high questionable payments in 2013 also had questionable payments in a prior year

The chiropractors with high questionable payments also received a total of nearly $100 million in questionable payments from 2009-2012 (see Figure 3). In addition, almost half of the chiropractors with high questionable payments in 2013 had at least one questionable payment in each year between 2009 and 2012, thus demonstrating that these chiropractors had a consistent pattern of questionable payments over a 5-year span.

In 2013, Medicare inappropriately paid $21 million for chiropractic services lacking a covered primary diagnosis

Thirty-nine percent of chiropractors received a total of $20.7 million for claims that lacked a covered primary diagnosis code (see Table 9);29 We used CMS ‘s guidance and MACs’ local coverage determinations to identify claims that lacked a primary diagnosis covered by Medicare. All MACs but one have local coverage determinations that align with CMS’s guidance. That one MAC has a local coverage determination allowing coverage of chiropractic services for 209 primary diagnoses, but it does not include the diagnosis codes for nonallopathic lesions. As a result, we did not count the payments for claims with these 209 primary diagnoses in this MAC’s jurisdiction as inappropriate.30 The other two measures of inappropriate payment that we analyzed— claims for duplicate services and claims lacking the AT modifier— identified only about a thousand claims that totaled $27,259.

Stay tuned next week for the conclusion to the OIG report on chiropractors.

All information sourced from OIG website here.