OIG Medicare report says DCs ‘overpaid’ by $285M in 2001

WCA disputes conclusion, citing implied 12 visit limit

A report from the US Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS) claims that, in 2001, two out of every three dollars paid to chiropractors by Medicare were for services that “should not have been billed to Medicare.” The report, titled “Chiropractic Services in the Medicare Program: Payment Vulnerability Analysis,” was released in June.

According to the report, the majority of the nearly $285 million in “inappropriate” payments were for maintenance services. By law, the Medicare program covers only “manual manipulation of the spine to correct a subluxation, or malfunction of the spine.” Federal regulations further limit Medicare payment to “treatment of subluxations that result in a neuromusculoskeletal condition for which manual manipulation is appropriate treatment.” All services billed to Medicare must be “medically necessary and supported by documentation,” the report added.

Over the $285 million, $186 million went for maintenance treatments, which Medicare defines as medically unnecessary, and therefore not covered. “Another 14% ($65 million) were found to be medically unnecessary for other reasons,” the report noted.  “Medicare also allowed $24 million for services billed with a spinal manipulation code that were actually extraspinal manipulations or non-manipulative treatment, such as massage.  Apart from coverage issues, upcoding was also a significant problem, resulting in a $15 million overpayment.”

The report recommended the elimination of payments for maintenance services as well as a cap on the number of visits a Medicare patient could receive chiropractic. “When chiropractic care extends beyond 12 treatments in a year, it becomes increasingly likely that individual services are not medically necessary,” the report says.

Although the report noted that the OIG “contracted with practicing chiropractors to review each service according to a standard protocol, which was based on Medicare coverage guidelines and requirements,” it also admitted that these reviewers “noted that some of this treatment was acceptable from a chiropractic standpoint, and may have been beneficial to the patient.”

According to Matthew McCoy, DC, a member of the Board of Directors of the World Chiropractic Alliance and editor of Journal of Vertebral Subluxation Research, the report raises several important issues but comes to the wrong conclusion in implying that chiropractors are either deliberately defrauding the program or providing unnecessary services.

“I think it’s important to put it all in perspective financially,” Dr. McCoy noted. “The total Medicare budget hovers around $250 billion a year with approximately $400 million of that being paid to chiropractors. This payment to chiropractors represents .16% of the total budget. For the inspector general to suggest that capping chiropractic services would significantly save taxpayer money is debatable.”

He also pointed to several important chiropractic studies that demonstrate the potential cost savings to the Medicare population from those under chiropractic care. In one, researchers performed an analysis of an insurance database, comparing persons receiving chiropractic care with non-chiropractic patients. The study consisted of senior citizens over 75 years of age. It was reported that the individuals receiving chiropractic care reported better overall health, spent fewer days in hospitals and nursing homes, used fewer prescription drugs, and were more active than the non-chiropractic patients.

In the other study, researchers surveyed 311 chiropractic patients, aged 65 years and older, who had received “maintenance care” for five years or longer. The research concluded that chiropractic patients receiving maintenance care, when compared with US citizens of the same age, spent just 31% of the national average for health care services. There was a 50% reduction in medical provider visits. The health habits of patients receiving maintenance care were better overall than the general population, including decreased use of cigarettes and decreased use of nonprescription drugs. Furthermore, 95.8% believed the care to be either “considerably” or “extremely” valuable.

McCoy also referenced research that provided evidence of chiropractic’s beneficial impact on overall health and quality of life.

In one such project -- the largest study of its kind ever undertaken regarding a chiropractic population -- Robert Blanks, PhD and colleagues surveying 2,818 respondents in 156 clinics found a strong connection between persons receiving chiropractic care and self-reported improvement in health, wellness and quality-of-life. Some 95% of respondents reported that their expectations had been met, and 99% wished to continue care.

Another report found that 79% of chiropractic patients have maintenance care recommended to them, and nearly half of those comply. In an online survey with 3,018 respondents, 62% responded affirmatively when asked, “Although you feel healthy, would you follow your family member’s lead and visit a doctor who focuses on wellness and prevention just so you can stay feeling that way?”

“Even to the layperson it’s obvious that improvements in such basic physiological functions translate into improved quality of life for the elderly population,” McCoy stated. “Contrary to the inspector general’s report it may be more likely that increasing chiropractic coverage would lead to a significant savings to the taxpayer.”

McCoy also explained that, in order to address the claim that care exceeding 12 visits is probably not ‘medically’ necessary, “one needs to understand how Medicare defines medical necessity for the purposes of chiropractic care. First and foremost the patient must have documented evidence of a vertebral subluxation. Recently, the issue of how to identify the clinical presence of a subluxation for Medicare was clarified through the adoption of the P.A.R.T. model of clinical evaluation. Unfortunately, the IG’s report looked at data prior to the implementation of this model.”

Secondly, Medicare requires the co-existence of a related disease or disorder to the subluxation in order for the care to be considered medically necessary, he added. “This requirement is contradictory to established standards of practice within the chiropractic community,” he pointed out. “Chiropractic educational institutions and national associations hold that vertebral subluxation is an acceptable stand alone diagnosis and that the patient does not have to be exhibiting symptomatic manifestations of any related or unrelated disease or disorder in order to be entitled to chiropractic care directed at reducing the subluxation. This practice is akin to a dentist treating the early stages of dental cavities. Further to this is the distinction that the subluxation itself can be categorized as acute or chronic.”

He concluded: “The problem with these issues resides in the misinterpretation by the government of chiropractic standards of care in the context of care directed at vertebral subluxation management. These are no doubt long term problems that will need to be addressed by the national chiropractic associations and such efforts are currently underway.”