The Sep 2015 OIG Report:  Questionable Payments
Written by Editor   
Monday, November 02, 2015 08:05 AM

In September of 2015 the Office of the Inspector General (OIG) of the Department of Health and Human Services, a federal agency, released a report highlighting its evaluation of chiropractic claims and questionable and inappropriate payments for chiropractic services. This article looks at the findings of the OIG study, specifically their determination of “questionable payments.”  How does the OIG determine which paid claims are questionable? This article reports the criteria that the OIG used to determine if a claim was questionable. 

The OIG states “we developed four measures to identify paid claims that were questionable.  We based these measures on previous OIG reports and fraud investigations, interviews with experts in chiropractic practice and fraud detection, and our own analysis."

These measures include “treatment suggestive of maintenance therapy”, “potentially uploaded claims”, “potential sharing of beneficiaries”, and an “unlikely number of services per day."

Says the OIG “a high average number of claims per beneficiary per chiropractor suggests billing for services that were not active treatment.”  The OIG has observed that the more services that are provided to a beneficiary, the more likely it is that the services are medically unnecessary or maintenance treatment.  “We determined that 20 services per beneficiary was the threshold for this measure.  We identified as an outlier any chiropractor whose average number of paid claims per beneficiary exceeded the threshold.  For these chiropractors, we identified their beneficiaries who had treatments in excess of the threshold and considered all claims associated with these beneficiaries to be questionable.” 

The OIG also notes that “a high average ‘physician work relative value unit’ (RVU) for a chiropractor’s claims suggests billing for services at a higher level than warranted.  Only about 10 percent of all paid chiropractic services are for the highest CPT code, 98942.”  The OIG has observed that almost half of the chiropractic services coded with CPT code 98942 were upcoded.

“We counted CPT code 98940 as 0.45 work RVUs, CPT code 98941 as 0.65 work RVUs, and CPT code 98942 as 0.87 work RVUs. … we determined that 0.85 was the threshold” for upcoding.  “For the chiropractors that had average work RVUs greater than the threshold, we considered all of their claims for CPT code 98942 to be questionable."

“A high average percentage of a chiropractor’s beneficiaries who received services from other chiropractors suggests the misuse of beneficiary identification numbers.”  The OIG notes that “chiropractors with a high percentage of beneficiaries receiving treatments from other chiropractors may be involved with fraud schemes, such as medical identity theft or kickback arrangements.”   The OIG “identified the threshold as 52.5 percent of a chiropractor’s beneficiaries who received services from another chiropractor.  For chiropractors whose percentage exceeded the threshold, we considered all of their payments for the beneficiaries seen by other chiropractors to be questionable."

Finally, the OIG states “a high number of hours of services provided by a chiropractor on 1 day suggests billing for services of diminished quality and/or for services that were not rendered.”  The OIG determined this threshold by counting “CPT code 98940 as 12 minutes, CPT code 98941 as 17 minutes, and CPT code 98942 as 21 minutes.  We then calculated the number of hours per day for each chiropractor’s paid services.  We established 16 hours [960 minutes] as the threshold for this measure.  We considered all of a chiropractor’s claims on any day that met or exceeded the threshold as questionable.

Using these numbers, the OIG is suspect of those providing more than the following:

98940     960 minutes/12 minutes = 80 per day
98941     960 minutes/17 minutes = 56 per day

98942     960 minutes/21 minutes = 45 per day

The following are the thresholds for being considered an outlier, and actual Medicare statistics for each of these four measures:

Treatment suggestive of maintenance therapy (> 20 per beneficiary):  The threshold to be considered an outlier was 20 services per beneficiary.  Actual use statistics ranged from a maximum of 160 services per beneficiary, to a minimum of 1 service per beneficiary with a median of 8 services.  There were 1,271,815 of these claims representing 6.5% of total Medicare paid claims.

Potential sharing of beneficiaries (> 52.4% of Medicare patients see another DC):  The threshold to be considered an outlier was 52.5% of a chiropractor’s beneficiaries having paid claims from another chiropractor.  Actual use statistics ranged from a minimum of 100% of beneficiaries meeting this criteria, and a minimum of 0%, the median was 13% of beneficiaries having potential sharing of beneficiaries.  There were 988,926 claims representing 5.0% of total Medicare paid claims.  

Potential uploading of claims (> a 0.85 RVU use):  The threshold to be considered an outlier was for an average of 0.85 RVU per service.  Actual use statistics ranged from a maximum RVU per service of 0.87 and a minimum of 0.45, the median RVU per service was 0.63 RVUs.  There were 603,655 claims representing 3.1% of paid Medicare paid claims.  

Unlikely number of services per day (> 16 hours per day): The threshold to be considered an outlier was for services to total more than 16 hours in one day.  Actual use statistics ranged from a maximum of 28.62 hours, and a minimum of 0.20 hours claimed in one day, the median was 0.57 hours.  There were 24,465 claims representing 0.1% of total Medicare paid claims.