The Pitfalls of Being a Chiropractic Medicare Provider


In May of 2009, the Office of Inspector General (OIG) issued a report which revealed that, out of $466 million paid to chiropractic providers in 2006, “Medicare inappropriately paid $178 million…representing 47 percent of claims.” Put another way, almost one out of every two claims is filed improperly by chiropractors. As the OIG believes, this is a situation where they have grossly overpaid.

The Inspector General further reported that these “inappropriate” payments were due to the claims that were erroneous in one of three ways. First, some were classified as being miscoded (this amount being responsible for $11 million of the payments). Second, some were undocumented (approximately $46 million of the total). And third, the remaining amount ($157 million) were for services considered “maintenance therapy”; a service not covered under Medicare benefits.

So what does this mean if you’re a chiropractor who takes Medicare payments? It means you should be prepared for not if an audit happens but when.

Audits = Consequences

If you’re audited and determined to be one of the chiropractors who has been overpaid, it’s important to know that the OIG has told the Centers for Medicare & Medicaid Services (CMS) to encourage contractors to “take any necessary corrective action” to remediate this issue.

Furthermore, in a September 2015 report which stated that there were still $76 million in “questionable” chiropractic service payments, the OIG asks CMS to “collect overpayments based on inappropriately paid claims.”

In other words, they’re coming after you for the money.

Certified EHR’s: Your Best Defense

The best defense to avoid issues like this is to implement Medicare-approved documentation and billing procedures as it keeps you off their radar and reduces your likelihood of an audit. This involves having a certified electronic health records (EHR) system. Certified EHRs improve your documentation and billing standards so your risk of billing for inappropriate services is minimized.

A certified EHR also comes with additional benefits such as faster documentation, quicker access to records, more data security, and ultimately better quality of care. And it does this while increasing your collections and overhead, resulting in a more profitable practice for you.

Using this type of system also helps you avoid meaningful use (MU) payment penalties. These were one percent in 2015, but projected to be two percent in 2016 and raising one percentage point every year after that. Penalties associated with the Physician Quality Reporting System (PQRS) administered by CMS are on the rise as well, going from 1.5 percent in 2015 to two percent in 2016 and beyond.

Assign a Quality Control Specialist

Another way to protect your chiropractic practice from being audited is to assign one of your staff as a quality control specialist. Essentially, this person would perform an internal audit, potentially saving you a lot of money, as well as frustration and time.

Your quality control specialist would also be responsible for looking at your records and coding practices – quarterly or semi-annually – for documentation discrepancies.

At a minimum, if the CMS sees that you are taking actions to make sure you’re Medicare compliant, they will likely have a more relaxed approach with regards to your record-keeping. They may even excuse minor violations since you’re taking actions to attempt to comply with their requirements.

The Future of Chiropractic Medicare Providers

Because the OIG continues to see millions in inappropriately paid claims by chiropractors, you can expect to be under CMS’s watchful eye for quite some time. Thus, taking actions now to be “above board” and fully compliant with your record keeping and reporting standards can save you a lot of hassle, as well as a lot of money in repayments and fines.

This involves finding ways to monitor your practice so you can identify and correct problems before an audit. It also means implementing systems that make it more difficult to be non-compliant, one of which is a certified EHR.

Looking after your chiropractic business and ensuring that you’re documenting records and billing claims appropriately are all part of being a responsible business owner. And once you attain this status, it’s possible that your reputation will help keep you from being audited in the first place!