CMS Should Use Targeted Tactics to Curb Questionable and Inappropriate Payments for Chiropractic Services

WHY WE DID THIS STUDY

Chiropractic services have the highest rate of improper payments among Part B services, according to the Centers for Medicare & Medicaid Services' (CMS) Comprehensive Error Rate Testing program. Medicare covers chiropractic services to improve function, which it refers to as "active treatment," but does not cover "maintenance therapy," which is when further clinical improvement cannot be reasonably expected from ongoing treatment. Past OIG work has found that between 40 and 47 percent of all paid chiropractic claims were for maintenance therapy. In addition, Medicare fraud cases suggest that vulnerabilities exist relative to other Medicare services for beneficiaries receiving chiropractic services, such as physical therapy.

HOW WE DID THIS STUDY

We analyzed paid claims for chiropractic services from 2013 to identify chiropractors who exhibited questionable billing using four measures: (1) treatment suggestive of maintenance therapy, (2) potential sharing of beneficiaries, (3) potentially "upcoded" claims, and (4) unlikely number of services per day. We then identified chiropractors who received high amounts of questionable payments. For these chiropractors, we determined their locations, past questionable payments, and whether their beneficiaries received same-day physical and occupational therapy. We also identified inappropriate payments for claims not meeting certain Medicare requirements.

WHAT WE FOUND

In 2013, $76 million in Medicare payments for chiropractic services were questionable. Almost half of the questionable payments were for claims suggestive of maintenance therapy. In addition, just 2 percent of chiropractors were responsible for half of the questionable payments. These chiropractors provided more services to more beneficiaries compared to all other chiropractors and were located in high-fraud areas. Beneficiaries of these chiropractors were more likely to have had paid claims for physical and occupational therapy on the same day than were beneficiaries treated by other chiropractors, especially in high-fraud areas. Most of these chiropractors also had questionable payments in a prior year. Lastly, in 2013, Medicare inappropriately paid $21 million for chiropractic services that lacked a primary diagnosis covered by Medicare.

WHAT WE RECOMMEND

CMS should (1) establish a more reliable control for identifying active treatment, which would enable CMS to identify potential maintenance therapy; (2) develop and use measures to identify questionable payments for chiropractic services; (3) take appropriate action on the chiropractors with questionable payments; (4) collect overpayments based on inappropriately paid claims; and (5) ensure that claims are paid only for Medicare-covered diagnoses. CMS did not concur with our first recommendation, citing significant obstacles and stating that new medical review requirements would address our concerns; we disagree because the requirements target a narrow group of chiropractors who are not necessarily receiving payments for maintenance therapy. CMS concurred with our other recommendations.