Chiropractic News

The OIG and your practice
By Marty Kotlar, DC, CHCC, CBCS

The Office of Inspector General (OIG) has made reports on chiropractic. How does that affect me and my practice?

The OIG protects the integrity of Department of Health and Human Services (HHS) programs, as well as the health and welfare of the beneficiaries of those programs.

The OIG conducts investigations of fraud and misconduct to safeguard the HHS’ programs, and the duties of the OIG are carried out through a nationwide network of audits, investigations, inspections, and other mission-related functions performed by OIG components.

Investigative activities are designed to detect and prevent waste, fraud, and abuse in department programs. Investigations can result in criminal investigations and program exclusions; recovery of damages and penalties through civil and administrative proceedings; and corrective management actions, regulations, or legislation.

The OIG receives thousands of complaints each year from various sources brought to its attention for development, investigation, and appropriate resolution.

The OIG devotes significant resources to the investigation of fraud committed against Medicare and Medicaid. It conducts numerous investigations with other law-enforcement agencies, such as the Federal Bureau of Investigation, the United States Postal Inspection Service, the Internal Revenue Service, and State Medicaid Fraud Control Units.

The OIG investigates individuals, facilities, or entities that bill or are alleged to have billed Medicare and/or Medicaid for services not rendered, claims that manipulate payment codes in an effort to inflate reimbursement amounts, and other false claims submitted to obtain program funds.

It also investigates business arrangements that allegedly violate the federal healthcare anti-kickback statute and the statutory limitation on self-referrals by physicians. The OIG investigates matters involving enrollment and marketing schemes, prescription shorting, and healthcare fraud.

The OIG does not pursue legal action against individuals, facilities, or entities that merely make mistakes on claims submitted to Medicare or Medicaid. CMS and its contractors address claims errors and mistakes. The OIG works with the CMS program safeguard contractors to identify specific patterns of misconduct by reviewing a compilation of integrated Medicare Parts A, B, and C, and Medicaid claims.

The OIG has authority to exclude individuals and entities from participation in Medicare, Medicaid, and all federal healthcare programs to protect the programs and beneficiaries from providers who pose a risk.

Providers are excluded for reasons that include program-related convictions, patient abuse or neglect convictions, and licensing board disciplinary actions. The OIG imposes exclusions based on referrals received from various federal and state agencies. It works with these agencies to ensure the timely referral of convictions and licensing board and administrative actions.

The OIG encourages healthcare providers to promptly self-disclose improper conduct that violates federal healthcare program requirements. It has made a concerted effort to educate providers on the advantages of self-disclosure.

In October 1998, the OIG announced a self-disclosure protocol for use by all healthcare providers. The protocol offers healthcare providers specific steps, including a detailed audit methodology they may use if they choose to work openly and cooperatively with OIG.

Numerous providers have been accepted under this protocol. These providers range from hospitals to laboratories and physicians. Both the federal government and the providers benefit from this program.

The self-disclosure protocol is designed only for providers who believe a potential violation of the law has occurred. Matters exclusively involving overpayments or errors that do not indicate violations of the law should be brought directly to the attention of the entity responsible for claim processing and payment.

Each year the OIG writes a work plan. The OIG work plan sets forth various projects to be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General.

The 2008 OIG work plan specifically addresses chiropractic services — payments for high-frequency treatments, Medicare “incident-to” services, and outpatient therapy services:

• Payments for high-frequency chiropractic treatments. The OIG reviews chiropractic billings for high-frequency treatments to determine whether they comply with Medicare coverage criteria and documentation requirements.

High frequency refers to a potentially excessive number of treatments or outliers to guidelines or standards of care. CMS includes chiropractors as physicians, but only for treatment by manual manipulation of the spine to correct subluxations 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. Sections 1862(a)(1)(A) and 1833(e) of the Social Security Act state Medicare pay for services only if medically necessary and supported by documentation.

Prior OIG reports found that 40 percent of chiropractic services were for maintenance therapy and thus did not meet Medicare coverage criteria, potentially costing approximately $186 million in improper payments.

The OIG will determine the appropriateness of Medicare payments for high-frequency chiropractic claims.

• Medicare ‘incident-to’ services. Medicare Part B generally pays for services incident to a physician’s professional service; such services are typically performed by a nonphysician staff member in the physician’s office. Federal regulations specify criteria for “incident-to” services.

The OIG will review Medicare claims for services furnished incident to the professional services of selected physicians.

The OIG will examine the Medicare services that selected physicians bill incident to their professional services and the qualifications and appropriateness of the staff who perform them.

• Therapy services provided by comprehensive outpatient rehab facilities. Section 1861(cc)(2) of the Social Security Act governs comprehensive outpatient rehabilitation facilities (CORFs). A CORF is a provider of services paid under the physician fee schedule for most services.

Prior OIG reviews have found that Medicare paid significant amounts for unallowable or highly questionable therapy services in outpatient rehabilitation facilities and nursing homes. A majority of these services were not reasonable and necessary for the beneficiary’s health condition or lacked sufficient documentation.

The OIG will review the appropriateness of Medicare claims submitted by CORF for physical therapy, speech language pathology, and occupational therapy services.

It will determine whether Medicare payments for therapy services were made in accordance with applicable Medicare requirements.

Marty Kotlar, DC, CHCC, CBCS, is the president of Target Coding. Target Coding, in conjunction with Foot Levelers, offers continuing-education seminars on CPT coding and compliant documentation. He can be reached at 800-270-7044, by e-mail at drkotlar@targetcoding.com, or through the Web site, www.targetcoding.com.