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Medicare Improperly Paid Providers for Items and Services Ordered by Chiropractors

Coverage of chiropractic services is specifically limited to treatment through manual manipulation, i.e., by use of the hands. Medicare does not cover any other diagnostic or therapeutic service provided by a chiropractor or under a chiropractor’s order.

Medicare payments for selected items and services ordered by chiropractors did not comply with Federal requirements. Specifically, for calendar years 2013 through 2016 (audit period), Medicare improperly paid providers $6.7 million. As of the publication of this report, this improper payment amount includes claims outside of the 4-year claim-reopening period.

Medicare overpaid providers because the Centers for Medicare & Medicaid Services’ (CMS’s) claims processing edits were not fully effective in preventing overpayments. Although CMS began using claims processing edits on October 5, 2009, to issue an informational message to alert a billing provider that a chiropractor was not eligible to order an item or a service billed, CMS did not begin using these edits to deny claims until January 6, 2014. Of the $6.7 million in improper payments for our audit period, $5.9 million (89 percent) were for items and services in calendar year 2013, before CMS’s implementation of the January 2014 edits.

We recommended that CMS direct the Medicare contractors to recover the portion of the $6.7 million in overpayments to providers for claims that are within the reopening period. We also recommended that CMS instruct the Medicare contractors to notify providers of potential overpayments so that those providers can exercise reasonable diligence to investigate and return any identified similar overpayments and identify and track any returned overpayments. Finally, we recommended that CMS revise the claims processing edits to ensure that all claims for items and services ordered by chiropractors are denied.

CMS concurred with our first and second recommendations and provided information on actions that it planned to take to address those recommendations. However, CMS did not concur with our third recommendation and stated that the existing claims processing edits already deny payment for the majority of improper payments related to ordering chiropractors. Although CMS’s implementation of the 2014 edits significantly reduced the number of claims that Medicare paid for items or services ordered by chiropractors, revising the edits would identify additional claims that were unallowable for payment.

Filed under: Centers for Medicare and Medicaid Services