Office of Inspector General Releases Scathing Report on Chiropractic
The Office of the Inspector General of the Department of Health and Human Services released a report dated May 2009 entitled: Inappropriate Medicare Payments for Chiropractic Services. The stated objective of the report was to:
To determine the extent to which:
(1) chiropractic claims allowed in 2006 for beneficiaries receiving more than 12 services from the same chiropractor were appropriate,
(2) controls ensured that chiropractic claims were not for maintenance therapy,
(3) claims data can be used to identify maintenance therapy, and
(4) chiropractic claims were documented as required.
According to the OIG report, Medicare inappropriately paid $178 million for chiropractic claims in 2006. This was out of $466 million in total claims paid. According to the medical claims reviewers hired by the OIG to conduct this investigation, the bulk of the inappropriate payments were for maintenance therapy which amounted to $157 million. Miscoded and undocumented claims accounted for the rest.
This is not the first time the OIG has asserted that there were “significant vulnerabilities” related to Medicare payments for chiropractic care. Reports in 1986, 1998 and 1999 also alleged problems related to payment for maintenance therapy. In 2005 the OIG stated that 40 percent of allowed chiropractic claims were for maintenance therapy and they asserted that any visits over 12 in a year were likely to be for maintenance care.
“There are several concerns with this most recent report from the OIG that include methodology, bias, and most distressing – perhaps a complete lack of understanding regarding the nature of the management of vertebral subluxation.” Stated Matthew McCoy DC, MPH a chiropractor, public health researcher and Vice President of the Foundation for Vertebral Subluxation.
In a report that analyzed the OIG investigation McCoy details methodological concerns including that the OIG paid chiropractors to review these claims and used chiropractors who have a history of reviewing claims for Medicare carriers. Further concerns arise from disparaging comments towards chiropractors from Medicare carrier staff and medical reviewers contained within the report. Some comments even suggest widespread fraudulent conduct on the part of chiropractors participating in Medicare.
“These comments by carrier staff and medical reviewers are completely unsubstantiated and reveal significant bias and flaws in the study. They never should have been published and who knows what damage will be done to the credibility of the profession as a result” stated Dr. Christopher Kent a chiropractor, attorney and President of the Foundation for Vertebral Subluxation.
Medicare pays chiropractors for treatment to correct vertebral subluxations which are misalignments and/or abnormal movement of spinal bones that interfere with nerve function. However, Medicare will only pay for subluxation correction if there are other diseases, disorders or syndromes related to the subluxation – not for the correction of subluxation in and of itself. This, according to McCoy, is the fatal flaw in Medicare policy when it comes to chiropractic.
“Vertebral subluxations are detrimental in and of themselves – its like saying they won’t pay for the treatment of heart disease until you are in the midst of a heart attack” stated McCoy.
Making matters worse is an ongoing battle between chiropractors and the carriers who administer Medicare on how many visits it takes to correct a vertebral subluxation. The inappropriate payments alleged by the OIG may simply be a disconnect in determining whether the care being provided is corrective or what is commonly called maintenance care – Medicare will not pay for maintenance chiropractic care.
According to McCoy “The OIG, the carriers and the paid medical reviewers who work for them expect chiropractors to sit back and accept their allegations that all this care for seniors who typically suffer from a number of concurrent health conditions and have advanced spinal arthritis is unnecessary because it goes beyond 12 visits. Its ludicrous. Correcting a subluxation takes time and in this population a lot more than one month.”
In fact, research has not yet shown how long it takes on average to correct subluxations. For this reason doctors generally rely on standards of care and practice guidelines for guidance on how often and for how long someone needs care. “According to chiropractic practice guidelines accepted by the National Guideline Clearinghouse the parameters being used to measure subluxation should be monitored for reduction and stabilization of subluxation components” statedKent. “If these guidelines are good enough for the Agency for Healthcare Research and Policy why aren’t they good enough for Medicare?”
One problem with this approach is that Medicare will not pay chiropractors for anything except spinal manipulation which means that none of the tests that chiropractors routinely do to determine the severity of subluxation and monitor its correction are covered under Medicare. This leaves chiropractors in a Catch 22. It is also completely at odds with how all other providers are compensated under Medicare.
“How ridiculous is it that Medicare expects chiropractors to correct subluxations but will not pay for the tests necessary to determine if a patient has one or to determine if they have been corrected. Instead they arrive at this arbitrary 12 visit formula where everyone is supposed to be cured” remarked McCoy. “This is our tax dollars at work.”
Speaking of tax dollars, according to a review done by Dr. Curtis Fedorchuk the total cost of Medicare in 2006 was $339 billion with the total paid by Medicare to chiropractors totaling $187 million equaling .00055% of the total.
“That we are even arguing about this is symptomatic of the government’s failure to respond effectively to the health care crisis” stated Fedorchuk. “In at least two chiropractic studies on senior citizens we find that those seniors undergoing chiropractic use and spend less money on drugs, are hospitalized less, are less likely to end up in nursing homes, are more active and actually save Medicare money. Instead of trying to stop chiropractors from seeing Medicare patients they should be encouraging its use.”
In a series of policy recommendations the Foundation for Vertebral Subluxation recommends that chiropractors urge the Federal Government to change the professions role in Medicare and reimburse them for the care necessary to correct and monitor subluxations.
