by Dava Stewart
The Office of Inspector General (OIG) was established to identify and eliminate fraud, waste, and abuse in programs operated by the U.S. Department of Health and Human Services, including Medicare, by conducting investigations and audits. Each year, the OIG releases what is commonly referred to as a “Work Plan,” and the 2014 Work Plan specifically mentions three areas where chiropractors can expect to be audited.
There is anecdotal evidence that, as stimulus payments are made to DCs who attest to meaningful use of an electronic health records (EHR) system, audits are increasing in frequency. Although the government is encouraging practitioners to adopt EHR systems, the OIG exists in part to make sure those systems are being used for improving patient care and outcomes rather than increasing the incomes of practitioners.
The three areas that are specifically mentioned in the OIG Work Plan include:
1. A portfolio report on Medicare Part B payment
2. Part B payments for noncovered services
3. Questionable billing and maintenance therapy
Other areas may be audited as well, particularly for those who have attested to meaningful use of an EHR system. Auditors may want to see documentation that supports the attestation.
The portfolio report on Medicare Part B payments will focus on “prior OIG audits, evaluations, and investigations of chiropractic services paid by Medicare to identify trends in payment, compliance, and fraud vulnerabilities and offer recommendations to improve detected vulnerabilities,” according to the OIG website. In other words, the poor track record of chiropractic audits is going to result in closer inspections and investigations.
The rules regarding exactly what chiropractic services are covered under Medicare Part B are clear, and maintenance therapy is not covered. The Work Plan mentions investigating payments that may have been made for noncovered services, such as maintenance therapy. Two specific past investigations are mentioned, one from 2006, and one from 2013, and those investigations have prompted further inquiries from the OIG.
The last section of the Work Plan that is especially pertinent to DCs is “questionable billing and maintenance therapy,” and it is closely related to the prior section regarding payments for services that are not covered by Medicare. The OIG will be looking for trends that suggest billing for maintenance therapy. The report specifically mentions one DC with a 93 percent claims error rate that resulted in inappropriate Medicare payments of around $700,000.
The best course of action is for DCs and their staffs to make sure all records are in order. There are companies who will provide audits, and sometimes, outside advice is helpful. In many ways, the fact that the OIG performs these audits is a good thing. However, making sure all the details are covered and the records are in order will provide peace of mind and an added layer of protection.