Hundreds of Millions in Medicare Payments for Chiropractic Services Did Not Comply With Medicare Requirements

Most Medicare payments for chiropractic services did not comply with Medicare requirements. On the basis of our sample results, we estimated that $358.8 million, or approximately 82 percent, of the $438.1 million paid by Medicare for chiropractic services was unallowable. These overpayments occurred because CMS's controls were not effective in preventing payments for medically unnecessary chiropractic services.

Strong controls to prevent improper payments for chiropractic services are important to program integrity. For example, CMS could consider taking appropriate action to limit the number of chiropractic services that Medicare will reimburse to a specified maximum (e.g., 30 per beneficiary per year). If such a limit had been in place during our audit period, it would have prevented chiropractors from billing a high number of medically unnecessary services. Unless CMS implements strong controls, it is likely to continue to make improper payments to chiropractors.

We recommended that CMS do the following, which could have saved Medicare an estimated $358.8 million for 2013: (1) determine a reasonable number of chiropractic services that are necessary to actively treat spinal subluxation and implement a system edit to identify services for review in excess of that number; (2) determine a reasonable limit for the number of chiropractic services that Medicare will reimburse, take appropriate action to put that limit into effect, and implement a system edit to disallow services in excess of that limit; (3) improve education of chiropractors on Medicare coverage requirements for chiropractic services and the proper use of the AT modifier to ensure that only medically necessary chiropractic services are billed to Medicare; and (4) specifically identify significant obstacles to developing a more reliable control for identifying maintenance therapy and work to establish such a control.