The Sep 2015 OIG Report: Inappropriate Payments
Written by Editor   
Monday, November 09, 2015 11:40 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.

“We developed three measures to identify paid claims that did not meet Medicare requirements for payment,” the OIG report states.  These are noted to be claims lacking a covered primary diagnosis; claims for duplicate services; and claims lacking the AT modifier.

Claims lacking a covered primary diagnosis were "claims that lacked a primary diagnosis code that was covered by Medicare based on CMS’s guidance and the local coverage determination where the chiropractic service was provided.”  There were found to be 808,971 claims or 4.1% of total Medicare paid claims meeting this description.

Claims for duplicate services were “for services provided on the same day for the same beneficiary with the same diagnosis and procedure codes and the same chiropractor.”  There were found to be 970 claims, or less than 1% of total Medicare paid claims, meeting this description.

Claims lacking the AT modifier  were claims that “lacked the AT modifier, which indicates active treatment and is required for payment.” There were found to be 61 claims meeting this description totaling much less than 1% of total Medicare paid claims.

The OIG reports the total number of Chiropractic claims, and those claims questionably, inappropriately, or both questionably and inappropriately paid by Medicare. 

  • While 81.4% of the chiropractic professions claims were correctly paid,

  • only 0.7% were both inappropriate and questionable. 

  • 3.4% were inappropriately paid, and

  • 14.4% were “questionable” in the mind of the OIG because a beneficiary may have been seen 12 or more times in one year, because the beneficiary saw more than one chiropractic doctor, because claims were potentially uploaded, or an unlikely number of services were rendered in a day.

What are the most common questionable practices?

  • The OIG notes this to be potential sharing of beneficiaries reported to be 9.3% of chiropractors with questionable claims,

  • followed by treatment suggestive of maintenance therapy with 3.9% of chiropractors with questionable claims.

Using the OIG’s numbers we see that:

  • There were a total of 43,284 DC who filed claims in 2013. 

  • There were 7191 (16%) of DCs who filed Medicare claims with "questionable claims”:

    • 4216 (9%) DCs who filed claims indicating potential sharing of beneficiaries.

    • 1787 (4%) DCs who filed claims indicating treatment suggestive of maintenance therapy.

    • 1450 (3%) DCs who filed claims indicating potentially uploaded claims.

    • 16 (less than one-half of one percent) DCs who filed claims indicating an unlikely number of services per day

    • 962 (2%) of DCs filing Medicare claims received half of all questionable claims payments, receiving an average of $39,555 per year for each DC.

    • The remaining 6229 DCs were paid questionable-claims payments averaging $6000 per year for each DC.