Patient Options has been examining the OIG of September 2015 and how the government investigates fraud. This post will bring us to the Conclusions and recommendations that the OIG has come to after sifting through all the data. As you read the following pay attention that in 2013 they found that 20% or 1 in 5 payments were questionable in their eyes. Can you afford to pay back 1/5 of all of your claims? The shift of how MACRA came to be and how their are now oversight provisions in place for chiropractors is demonstrated as well.

Previous OIG work and the CERT identified questionable and inappropriate payments for chiropractic services as a longstanding concern. In this study, we used four measures to identify Medicare payments to chiropractors with billing characteristics that raise program integrity concerns, as well as payments for claims that did not meet certain Medicare rules for payment. We found that in 2013, nearly 20 percent of the payments for chiropractic services were questionable or inappropriate, based on these measures and selected requirements. Especially concerning is that just 2 percent of chiropractors paid by Medicare in 2013 received half of the questionable payments. Many of these 962 chiropractors had a history of receiving questionable payments in prior years and/or were located in high-fraud areas. Although this study did not determine whether the questionable payments we identified for chiropractic services were fraudulent or improper, the concentration of payments to these 962 chiropractors suggests that further scrutiny of them and their payments is warranted. In addition, over half of the questionable payments we identified were for treatment suggestive of maintenance therapy, and almost all of the inappropriate payments that we identified were for claims lacking a covered primary diagnosis. CMS instituted the AT modifier as a control to prevent Medicare from paying for maintenance therapy. However, the evidence in this study, as well as previous OIG work, shows that the AT modifier is not an effective safeguard. In addition, the payments for services with primary diagnoses other than subluxation indicate that Medicare paid for chiropractic services that did not meet coverage requirements. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which became law in April 2015, contains provisions for oversight of Medicare chiropractic services, including requiring preauthorization for services provided by chiropractors with aberrant billing or high rates of denial. Through targeted tactics that align with or complement these new provisions, CMS can address the vulnerabilities that we identify in this study.

We recommend that CMS: Establish a more reliable control for identifying active treatment Given that half of the questionable payments that we identified in 2013 were for treatment suggestive of maintenance therapy, CMS should devise a more reliable method for detecting it. As a first step, CMS could examine the date of initiation of treatment for a particular diagnosis reported on a chiropractic claim. Doing so would enable CMS to determine the length of a beneficiary’s chiropractic treatment and identify treatments likely to be maintenance therapy. CMS could also consider including this information in the National Claims History file so that it is available to Medicare contractors for pre- and post-payment review.

Develop and use measures to identify questionable payments for chiropractic services CMS could use these measures in a variety of ways. For example, it could use measures as part of its Fraud Prevention System to identify chiropractors for investigatory followup. It also could use measures to help its contractors identify and review potentially upcoded claims. In addition, it could use measures to identify and examine same-day services (such as therapy services) provided to beneficiaries, especially in high-fraud areas. Lastly, it could use measures to identify chiropractors who warrant pre- or post-payment review of services as called for in MACRA.

Take appropriate action on the chiropractors with questionable payments We identified 7,191 chiropractors with questionably paid claims, 962 of whom received half of the questionable payments. In a separate memorandum, we will provide CMS with information on chiropractors with high questionable payments, so that it may take action. CMS and/or its contractors should review their claims and take appropriate action. Such actions could include: (1) recouping inappropriate payments; (2) educating providers on proper billing; (3) making referrals to law enforcement; (4) imposing payment suspensions; (5) revoking billing privileges; or (6) taking no action, if the payment is determined to be appropriate.

Collect overpayments based on inappropriately paid claims CMS should collect the $20.7 million in payments that resulted from the inappropriate claims we identified. In a separate memorandum, we will refer these claims to CMS for collection.

Ensure that claims are paid only for Medicare-covered diagnoses Although Medicare requires a diagnosis of subluxation of the spine, no diagnosis code exists with that description. CMS should work with MACs to ensure that claims are paid for diagnosis codes that meet current and future Medicare coverage requirements. This would be a timely action to take, given that new diagnosis codes for subluxation will be used when ICD-10 is implemented in October 2015.32 In addition, CMS should assess whether the diagnosis codes that its MACs use in their local coverage determinations are consistent with national Medicare coverage policy.



Next post will cover how the agency has responded to this in depth report of chiropractors and fraud.

All information contained in this blog can be found here on the OIG website