Medicare Audit Letters Hit Chiropractic Offices Around the Country

This order further intensifies efforts to eliminate payment error, waste, fraud, and abuse in Federal program and requires federal agencies to conduct semi-annual studies to identify and reduce vulnerabilities in high risk areas. The chiropractic services study will focus on determining whether chiropractic services billed to Medicare were medically necessary acute chiropractic treatment. End Quote

(1888PressRelease) August 18, 2010 - Chiropractors are beginning to get an unwelcome surprise in their mailbox from Medicare carriers around the country as part of President Obama's Executive Order # 13520, "Reducing Improper Payments and Eliminating Waste in Federal Programs." This order further intensifies efforts to eliminate payment error, waste, fraud, and abuse in Federal program and requires federal agencies to conduct semi-annual studies to identify and reduce vulnerabilities in high risk areas.

Beginning mid-August 2010, The Centers for Medicare & Medicaid Services (CMS) is conducting these studies under the Comprehensive Error Rate Testing (CERT) program. Although the program is not targeting one specific group, chiropractors who submitted multiple claims for the same Medicare beneficiary between April and June 2010 may be part of the random sample group.

The chiropractic services study will focus on determining whether chiropractic services billed to Medicare were medically necessary acute chiropractic treatment. For each claim selected, CMS will review medical records up to 12 months prior to the date of service on the claim. CMS will deny claims for services determined to be maintenance therapy and recoup any overpayments.

According to Dr. Tom Necela, a chiropractor, Professional Coder and Certified Professional Medical Auditor, the most important thing to do when receiving a letter from the CERT Documentation Contractor is to comply with the audit records request. Because Dr. Necela's consulting firm, The Strategic Chiropractor, assists many doctors with such audit requests, he notes that "some chiropractors are afraid of submitting imperfect records out of the fear that their services will be denied." Necela cautions that "This reaction almost always makes the problem worse because the failure to respond to a record request will not only result in a denial, but may also result in the provider being charged with fraud."

Per Medicare regulations, providers receiving a records request have a time period of 30 days to respond. Medicare pays only for medically necessary acute chiropractic treatment. When further improvement cannot reasonably be expected from continuing care, the services are considered maintenance therapy and are not payable under Medicare. According to the recent study on chiropractic services in the Medicare system, the Office of Inspector General (OIG) found that the primary causes of the errors for chiropractic services were payments for maintenance therapy and missing plans of care.

Regardless of any possible documentation shortcomings, in order to avoid any potential violations and to ensure the proper handling of the records request, Dr. Necela recommends that providers submit their documentation immediately after receiving the request. "What you do after the CERT review" Necela notes, "is equally critical. That's the time to fix and prevent future negative reviews, post-payment demands and any other problems with your chiropractic billing, coding or documentation."

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