As greater numbers of chiropractors capitalize on the benefits of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, they should also be aware that more Medicare audits are on the way. 

The push for additional audits is fueled by two studies conducted by the Office of Inspector General in 2004 and 2006, respectively. The studies revealed problems in how chiropractors and regional carriers that administer and pay Medicare claims are doing their jobs.

The studies found that many chiropractors were not documenting their claims properly, often not distinguishing between active treatments (code AT) and maintenance therapy (code GA). The carriers did not seem to notice; for the most part they paid, not seeming to realize that Medicare’s intent was to pay only for active treatment, not for maintenance.

As for the chiropractors’ intent? Whether carelessness, ignorance of the rules, or even fraud, it doesn’t matter: Audits are coming and doctors had better be prepared.

The 2004 study

The 2004 study sought to determine the vulnerabilities associated with Medicare payments for chiropractic services, to find their causes, and thus find ways to reduce them. In conducting the study, the agency selected a random sample of 400 Medicare services, with a total amount of $12,638.38 that had been submitted by chiropractors and allowed by regional carriers in 2001.

Their findings were threefold:

• Maintenance services were the most common type of non-covered services paid to chiropractors by Medicare that year,
• Supporting documentation rarely met all the requirements of the Medicare Carriers Manual (many doctors simply categorized all treatments as active therapy), and
• Carrier controls to prevent over-utilization were inconsistent.

Accordingly, the agency issued two primary recommendations: that chiropractic services rendered comply with Medicare coverage criteria, and that carriers educate chiropractors on Medicare Carriers Manual requirements for supporting documentation. The recommendations were largely ignored, which precipitated the second study.

The 2006 study

Criteria for the second study were more directed and more detailed, analyzing four key factors:

• The appropriateness of claims allowed in 2006 for beneficiaries receiving more than 12 services from the same chiropractor,
• The controls in place to ensure that chiropractic claims were not for maintenance therapy,
• Assurance that claims could be used to identify maintenance therapy versus active therapy, and
• Evidence that chiropractic claims were documented as required.

The study reviewed a random sample of 188 claims to identify initial visits versus subsequent visits; whether each sample claim was for active/corrective treatment or maintenance therapy; the extent to which chiropractors supported their use of the AT modifier with proper documentation; whether claims were coded properly; and whether documentation met Manual requirements.

Four key findings emerged and were reported by the agency in 2009.

First, the extrapolated study revealed that of $178 million inappropriately paid for chiropractic claims — representing 47 percent of all claims studied — $147 million was for maintenance treatments. The balance went to miscoded claims ($11 million), undocumented claims ($46 million), and claims with multiple errors ($36 million).

Second, it showed that efforts to stop payment for maintenance therapy, by far the greatest of the improprieties, were largely ineffective.

Third, much of the claims data lacked initial visit dates for treatment episodes, making it difficult to identify maintenance therapy versus active treatment.

Finally, the study revealed that doctors still failed to comply with the CMS documentation requirements.

Again Medicare issued a set of recommendations, chief among which were the following:

• Implement and enforce policies to prevent future payments for maintenance therapy,
  • Review treatment episodes rather than individual chiropractic claims to strengthen the ability of the Comprehensive Error Rate Testing (CERT) program to detect errors,
  • Ensure that chiropractic claims are not paid unless documentation requirements are met, and
  • Take appropriate action on the undocumented, medically unnecessary, and miscoded claims identified in the sample.

  Once again, the recommendations were largely ignored and now, as the decade turns, Medicare is doing what it must do: take its own action in the form of increasing the number of audits it performs.

  The 15 regional carriers, groups like Palmetto GBA in Ohio and First Coast in Florida, will continue to administer and pay claims, but Washington, D.C., will remain actively in the picture through Medicare’s expanded audit policy.

  It is perfectly appropriate that Medicare proceed in this direction. The funds that it pays out come from taxpayer dollars and the agency is obliged to husband them effectively.

  What went wrong?

  It would be easy to assign blame to the chiropractors and the regional carriers. But where does the fault actually lie?

  The problem is not altogether with the chiropractors. Change is a constant in the healthcare field and chiropractors have few resources for continuing education, particularly in the business aspects of their practices. If there is fault, it is probably that the doctors typically have focused more intensively on treating their patients, visit-to-visit, than on true case management. If the patient says it hurts, [ITAL]it gets treated.[/ITAL]

  If there is fault on the side of the carriers, it probably stems from the fact that they did not educate their client chiropractors sufficiently on the differences between the AT and the GA modifiers. As a result, the doctors simply billed all treatments as active, since “a treatment is a treatment.”

  There has never been much education available in this area. In the absence of strong documentation, the tendency would bend toward exercising “best judgment,” which is inexact.

  The Centers for Medicare and Medicaid Services (CMS) is not taking this tack to punish chiropractors or the regional carrier administrators. It is doing so in order to staunch the flow of improper reimbursements, which can add up to millions of dollars, with the potential for even larger losses.

  The agency has decided that it cannot leave oversight up to the regional carriers and so it has established its own mechanism. Regional carriers will still continue to handle processing and payment.

  FULL STORY