Is your practice prepared for the coming 65-and-over patient wave? Chiropractic needs to be prepared for the numerous opportunities presented by an aging population and health care
Ten thousand people enroll in Medicare every day. By 2020, 64 million will be enrolled, and 80 million by 2030. By 2050, MedPAC estimates that people over 65 will represent more than 20% of the U.S. population.
Today’s aging population is healthier and living longer, and their goal is to continue living in their own homes. According to AARP, nearly 90% of people over age 65 want to stay at home for as long as possible. They have a mindset of, “Think health, not wealth.” Many in our profession still have reservations about treating Medicare patients, but we have never been better positioned to take care of this aging generation.
Viewing Medicare through the right lens
It is not surprising that many in our profession view Medicare negatively. The U.S. Office of Inspector General (OIG) has issued reports over the last several years defining critical issues related to chiropractic billing and documentation. In 2018, the OIG Work Report announced the highest rate of improper payment (from 2010-15) ranging from 43.9-54.1% for chiropractic services, compared with 9.9-12.9% for all other Part B services. As a result we have seen a rise in audits for Medicare patients throughout our profession.
In a recent interview with my friend R.J. Crawford, DC, he shared that many doctors who face the decision to participate with insurance and Medicare wonder, “Is it worth it?” This fear is due in large part to the stories and headlines across the country that make Medicare look worse than the boogeyman when it comes to the potential for audit or investigation that could lead to career-ending fines and penalties.
In discussing this with consultants around the country, I found there has been an increase in audits, but that it has not been limited to Medicare. As one consultant who has worked on hundreds of cases over the years stated, “only 24% of the cases I have consulted on were initiated by Medicare; the rest were undertaken by insurance companies.”
The silver tsunami
The onset of the “silver tsunami” is serious for those responsible for protecting the integrity of the Medicare fund in regard to the aging population and healthcare. They must ensure that those funds are available for the millions of beneficiaries who depend on them, and the millions more who will depend on them in the future.
Part of the problem with chiropractic and Medicare has been that each Medicare administrative contractor (MAC) separately defined their interpretation of Medicare policy. This left 12 potentially different interpretations. Medicare sees this as a problem.
“The good news,” said Scott Munsterman, DC, FICC, CPCO, an acknowledged expert on the transforming model of health care delivery, “is that work has been accomplished behind the scenes by Drs. Steve Conway and Michael Jacklitch, who worked one-on-one with chief medical directors of all of the Medicare contractors to arrive at a consensus in how Medicare policy for chiropractic care should be interpreted and implemented.”
Having a universal interpretation puts everyone on the same page, and Medicare is now using this universal approach to teach chiropractors and “claims reviewers” alike. Without this universal approach, chiropractors could have seen policy decisions that substantially restricted care for Medicare patients, the largest growing population in our country when discussing the aging population and healthcare.
Steve Conway, DC, JD, stated that the most common request he receives from chiropractors across the country is, “Just tell me what to do.” But he spends more time teaching them what not to do. Seem counter-intuitive?
“I find that many of us in the profession learn more from the mistakes of the past,” Conway says. And he’s right. As he and his good friends, Michael Jacklitch, DC, and Munsterman, continue to share the universal interpretation of policy from Medicare across the country, the error rate for chiropractic services billed is decreasing.
So what are the most common mistakes that Conway shares with his audience?
- Start-Over Diagnosis: This strategy is often used because the doctor was told by an “expert” that if you change the diagnosis, then everything starts over and you can keep treating the patient. The OIG is concerned about this approach because it doesn’t match the start-treat-release process of a true episode of care.
- No End in Sight: The doctor keeps treating a patient 2-3 times a week. The patient has pain and/or other functional deficiencies that the doctor uses as evidence for treatment. Here, there is no end in sight to the patient’s treatment plan — if this patient has a “treatment plan” at all.
- Keep Changing the Goal: I often hear the advice, “If you just continue setting mini-goals, and reaching them, then you can keep treating the patient.” The problem is that there is no “episode of care” with a definitive beginning, middle and end.
- Maintenance-Only Approach: Unfortunately, some “expert” told chiropractors that the way to avoid billing Medicare altogether (and to collect directly from patients) is to have them sign an ABN form on the initial visit. Of all the problems shared by Conway in his lectures, this one has the most serious consequences. The OIG views this practice as intentional fraud, and they are actively investigating these cases.
New Medicare legislation
In a November 2018 press release, the American Chiropractic Association announced that legislation had been introduced in the U.S. House of Representatives that would expand Medicare’s coverage of services provided by chiropractors within the scope of their license. The bill would allow Medicare beneficiaries to access the chiropractic profession’s wide-ranging, non-drug approach to pain management, which includes manual manipulation of the spine and extremities, joint mobilization, soft-tissue massage techniques, physiological therapies, exercise instruction and activity advice.
Access to non-drug approaches to pain management under Medicare, as well as private health care plans, has become increasingly important in the wake of the national opioid crisis, according to the ACA.
In 1906, statesman Winston Churchill said, “Where there is great power, there is a great responsibility. Where there is less power, there is less responsibility. And where there is no power, there can, I think, be no responsibility.” This statement has never been more applicable to our profession as it is today. Amid the opioid crisis, chiropractic has been acknowledged as a solution for pain management by the medical community, thereby giving us the power to be paid for the broad range of services we provide for our Medicare patients (Clinical Guidelines Committee of the American College of Physicians, 2017).
Meeting public demand
The public wants what chiropractic care offers. Other health care providers and payers are recognizing the effectiveness of chiropractic care. Patient satisfaction and experience ratings for chiropractic physicians are higher than for any other provider type. But, with all of this power and positioning comes a great responsibility for the entire profession to put what we know into practice and resolve our documentation issues once and for all.
Without continuing efforts to lower chiropractic error rates with Medicare, the request to expand coverage will fall on deaf ears in Congress, CMS and the Office of Inspector General. The silver tsunami will show up in our offices. Let’s start showing up for them and learning how we can all improve, standardize Medicare policy across the nation, and improve our documentation and efforts to educate the Medicare reviewers.
This isn’t just an “us” problem; it’s a congressional problem, a policy problem and a Medicare (MAC) problem. It is time to stop pointing fingers at all the stakeholders. Finding fault is easy, but finding a fix is more important — and we are on the way as a profession to doing just that.
RAY FOXWORTH, DC, FICC, MCS-P, is president of ChiroHealthUSA and a certified medical compliance specialist. He maintains his practice on NewSouth Professional Campus in Flowood, Miss., home to a large multidisciplinary spine center, with services ranging from chiropractic to neurosurgery. He can be contacted through chirohealthusa.com.