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Medicare Audit Letters Hit Chiropractors Starting August 2010

Every Medicare carrier in the country has been assaulting my inbox recently with “ALERT” emails designed to make chiropractors aware of studies being conducted by the Comprehensive Error Rate Testing (CERT) program.  I am not sure if we are at the equivalent of Code Orange or Code Red at this point, but the profession is definitely on Medicare’s “elevated risk” alert system in some fashion.  So, in case you haven’t heard, may this post serve to Paul Revere the chiropractic community to be on guard — Medicare is coming, Medicare is coming!

If the present has not already arrived, 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.

So…beginning NOW  (mid-August 2010), Medicare carriers will begin stepping up recovery efforts and unleashing a fleet of CERT (Comprehensive Error Rate Testing) letters aimed at chiropractors..  Although the program is not targeting chiropractors specifically (all Medicare providers are under similar attack), they have made the chiropractic targets public knowledge.  Chiropractors who meet the following criteria will be subjected to “random” audits:

  • Chiropractors who have submitted multiple claims for the same Medicare beneficiary between April and June 2010
  • The CERT audits will focus on determining whether chiropractic services billed to Medicare were medically necessary as acute (active) chiropractic treatment.
  • For each claim selected, CMS will review medical records up to 12 months prior to the date of service on the claim.

Based on the “random” criteria listed above, CMS will deny claims for services that the reviews have determined to be maintenance and not active treatment.  Accordingly, the Medicare carrier will then take steps to recoup any overpayments.

From my limited perspective of interacting with 14,000 readers of my chiropractic blog each week, speaking to seminar attendees and working personally chiropractic clients, my best guess is that these CERT criteria will fit…just about every chiropractor in the country.  I guess that would mean we are at Code Red.

Granted, all of our Medicare patients will not be seen multiple times between the April and June service dates, but I would bet that most offices have at least some patients who fit that criteria.  According to that logic, pretty much every chiropractor is a target for the latest, greatest “random” audit program to be unleashed to date. Code Orange at the least.

According to data published by Medicare in the press release for this new CERT launch, Medicare is going after $174.1 million in projected improper payments to chiropractors.   Admittedly, I’m not even sure how to interpret that large of a number in a meaningful context for you, me or the average chiropractor.  Taken across the board, that $174 million could mean every DC in the country would be forced to cough up roughly $3500.  Since a sizable chunk of DC’s on record are practicing part-time, retired, or not practicing at all, it’s possible that the 50,000 DC pool is much smaller.  In half, that would mean $7000 per DC.  Frankly, some of you don’t have anything to worry about because you see Medicare patients once every blue moon.  This conceivably can chop the available audit pool in half again, leaving all the remaining DC’s to foot a $14,000 bill.

Obviously, we can extrapolate these numbers to the point of complete paranoia and create a great case of analysis paralysis in which everyone freezes and does nothing.  But this really won’t help chiropractors dig out of this mess.

So here are a few brief recommendations to tackle this issue with a sober mind and some strategic planning:

  • The worst mistake is to ignore the CERT audit request. You have 30 days to comply.  Do it quickly.  If Medicare deems your documentation, billing or coding unworthy, they will ask for money back.  If they don’t even receive your documentation, they will still ask for their money back AND they can pursue the opportunity to charge you with fraud.
  • Medicare has stated that the primary causes of the errors were payments for maintenance therapy and missing plans of care. Two recommendations here: (1) if it walks, talks, quacks like a duck, it’s a duck.  When Mrs. Jones comes in like clockwork every first Monday of the month, with no rhyme or reason other than, it’s her scheduled appointment, it’s going to be a long hard road to prove that this visit is not maintenance.  (2)  Include a plan of care!  Some docs mistakenly think that they are flying “under the radar” by not documenting any scheduled visits.  If it’s PRN, say it’s PRN!  If you want them to come in 3x over the next 2 weeks, state that!  And remember, a treatment plan is more than a schedule of care (but that’s another topic for another day)
  • Seize the opportunity! Scared?  Some of you should be!  But being afraid accomplishes nothing. Face your fears and fix your shortcomings!  Get help instead of sitting there wondering if the Medicare monster is going to eat you for lunch.  No third party payer – Medicare included – expects your notes to be perfect.  In fact, I have been on training calls where imperfect notes are displayed for all to see as an example of what good documentation looks like.  Truth be told, your documentation should meet standards and if you want to keep yourself out of trouble, it should look better than your peers.  Why? Because, statistically speaking, many of your peers are getting it wrong – which is why we are in this mess in the first place.

The Final Word

For those of you who are feeling a bit paranoid, persecuted or just plain peeved, take heart: Medicare is not trying to eliminate chiropractic.  What they are trying to do is to clean up errors within their own systems – for physicians of all types – and in the process, reclaim money that should not have been paid out in the first place.  It may not seem fair that they have “suddenly” raised the bar. In actuality, the rules were there the whole time; they have recently taken the opportunity to enforce them.

And yes, it’s about the money.  When a cash-strapped government entity discovers that it can recoup $900 Million in incorrectly paid claims in about three years time, it wants to repeat that “experiment” over and over again.  If you haven’t been paying attention, that’s exactly what happened starting in 2005.  And the nearly $1 billion recovered was not just from chiropractors. In fact, we are only a small piece of the pie.  Unfortunately, the coffers are so empty, the powers that be want to scrape up every penny they can get back.

We do have the ability to defend ourselves here.  First, we can make sure our chiropractic billing, coding and documentation is as bulletproof as possible.  Then, our best defense will come in the fact that Medicare (and every other third party payer) may take a few pennies back from the chiropractic community, but it will cost them a few dollars to do it!

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