The Sep 2015 OIG Report:  “Maintenance Therapy"
Written by Editor   
Wednesday, October 21, 2015 12:00 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 why the OIG undertook the study.

The OIG is concerned that some 7000 out out of nearly 45,500 doctors of chiropractic nationwide are billing for maintenance therapy.  The OIG defines this as being more than 12 visits per year rather than by any actual medical necessity.  Stated another way, the OIG is concerned that more than 7000 DCs see some of their patients more than 12 times in a year.

The OIG reports that “in 2013, Medicare paid $502 million for chiropractic services provided by 45,490 chiropractors to almost 2 million beneficiaries.” It is interesting to note that these numbers indicate each doctor of chiropractic who treated a Medicare beneficiary received about $11,000 per year for treating all of their Medicare beneficiaries and that this results in a yearly “Medicare case average” of under $182 for every DC treating a Medicare beneficiary. 

The OIG identifies, however, that of this $502 million, some $76.1 million were for “claims that were questionable services based on our four measures of questionable payment.”  The OIG claims that these represent “15 percent of the Medicare payments for chiropractic services in 2013."

The OIG has identified that payment of “maintenance therapy” was the driver of all questionable payments stating “in total, 16 percent of chiropractors (7191) paid by Medicare in 2013 received questionable payments for chiropractic services.  Almost half of these payments were for claims suggestive of maintenance therapy, which we identified through high average numbers of claims per beneficiary per chiropractor.”

The factors that the OIG is using to identify “maintenance therapy” are “when chiropractic care extends beyond 12 treatments in a year, it becomes increasing likely that individual services are medically unnecessary…” 

The OIG bases this standard off of “OIG evaluations from 2005 and 2009 [that] found that between 40 and 47 percent of all paid chiropractic claims were for maintenance therapy,” and not upon scientific evidence, or medical record review. States the OIG “we did not conduct a medical record review to determine whether chiropractic services were medically necessary or had been coded correctly.” 

It seems to this author that the concept of “maintenance therapy equals more than 12 visits per year” is as unrealistic as presuming that all chiropractic doctors received only $181 per Medicare beneficiary per year.