2015 OIG Report

Office of Inspector General, U.S. Department of Health and Human Services.  (PRNewsFoto/Office of Inspector General Department of Health and Human Services)

HHS_OIG_Sept_2015In September the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) issued a new report targeting questionable and inappropriate payments for chiropractic services in Medicare.  In the report the OIG made several specific recommendations for action to be taken by the Centers for Medicare & Medicaid Services (CMS) that could affect you.  Once again our profession has been “targeted”, but a detail examination of the results of this study may surprise you. CERT reports continue to indicate the need for improved documentation, however, this report refutes past claims that almost 50% of  paid chiropractic claims were for maintenance care.  As a profession we do have a serious problem, however, it appears that our biggest  one is a  “2 per cent problem.”   Of the total $502 Million paid for chiropractic services, 81.4% was deemed “Neither inappropriately nor questionably paid”.  The report also admitted that the four measures that identified questionable payments did not provide conclusive evidence of improper or fraudulent payments. Rather, the measures were intended to identify Medicare payments to chiropractors that exceed those of other chiropractors in ways that raise program integrity concerns.” The most criticized area in past studies was related to the over-utilization of Medicare for the provision of “maintenance care”.  The statistical analysis of ALL claims for chiropractic services in 2013, however, revealed that 44,528 chiropractors (98%)  had an average of 8.65 paid claims per beneficiary for the entire year.  In addition to being high-volume providers, …  53% of the claims from the 962 (2%) were suggestive of maintenance therapy … and …“In contrast, just 3 percent of the claims for all other chiropractors (98%) paid by Medicare in 2013 were suggestive of maintenance therapy.”  Obviously, there is a huge difference from the past soundbite that ” over 50% of chiropractic claims are for maintenance care and inappropriate”, and the current revelation that only 3% of the claims from 98% of chiropractors are for maintenance care …”. This doesn’t mean that we don’t have a documentation problem, but it does mean that the past extrapolation of data received from the audited claims was not valid … probably because the samples were NOT RANDOM. It does mean, however, that if you as a chiropractor are operating in the parameters above the 98th percentile, your documentation validity and accuracy better be above the 98th percentile as well.

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