Medicare overpaid for most chiropractic services. Will patients have to repay?

WASHINGTON --- Are you a Medicare recipient? Do you use a chiropractor?

If the answer is yes to both questions, it's highly likely the federal government should not have paid for your services.

But don't worry: You won't have to pay Uncle Sam back.

Medicare is the federal health insurance program for the elderly and others with certain disabilities. It reimbursed chiropractors $438 million in 2013 for services to more than 17 million beneficiaries. About $359 million of that, approximately 82 percent, was wrongly paid, according to the Department of Health and Human Service's Office of Inspector General (IG).

Although the report released last week covers 2013, it provides no indication that the Centers for Medicare and Medicaid Services (CMS) that runs Medicare is doing a better job now. In fact, the report issued by Inspector General Daniel R. Levinson includes this warning: "Unless CMS implements strong controls, it is likely to continue to make improper payments to chiropractors."

Many people with back pain see chiropractors because they specialize in spinal manipulation. Medicare covers that, but only for active or corrective treatment of spinal subluxation or misalignment. Medicare does not consider maintenance therapy necessary, so the government will not pay for that. Maintenance therapy can prevent deterioration of some conditions.

Responding to the report, the American Chiropractic Association said it believes "the definition of maintenance care is ambiguous, that it is unclear how this definition was used to audit chiropractic records in the context of this specific report and that further research should be conducted to determine the medical necessity of maintenance care, which preliminary studies indicate may actually be of benefit to older adults."

Levinson's office investigated the chiropractic charges because a series of previous reports found ongoing problems with the payments. Four reports from 2013 to 2016 "found that Medicare made improper payments for chiropractic services that were medically unnecessary, incorrectly coded, insufficiently documented, or not documented," the new report said.

For this report, the IG reviewed a sample of 105 chiropractic services. Only 11 "were allowable in accordance with requirements," the IG said. That means almost nine out of 10 were not. The documentation provided by the chiropractors in the sample "did not support the medical necessity of the services," the IG found.

Because the IG's study was based on a sampling, CMS said it is not able to identify all the specific improper payments that could be pursued for repayment. So, the chiropractors who were reimbursed improperly and their patients need not fear that a federal bill collector will come calling.

Levinson's office said Medicare could have saved the $359 million had it followed the IG's recommendations for effective controls, including setting a reasonable number of visits to treat misaligned spinal bones. The IG said Medicare should determine if there should be a limit to the number of chiropractic service it will reimburse and develop a system to not allow services over that limit. Medicare also needs to better educate chiropractors on coverage requirements and work to establish a better method for identifying chiropractic maintenance therapy, according to the report.

In a reply to Levinson, CMS acting administrator Andrew M. Slavitt agreed with most of the IG's recommendations, but not the one that said Medicare should determine a reasonable limit on the number of chiropractic services it will reimburse.

"In order to implement this recommendation, CMS would need to develop a national coverage determination establishing a limit on the number of chiropractic services that are reasonable and necessary," Slavitt wrote. "CMS is not aware of medical evidence that would support such a determination."

Slavitt said his agency combats fraud, waste and abuse by "using a comprehensive program integrity strategy to educate providers, recoup improper payments, and protect taxpayer dollars. CMS has also worked to educate chiropractors on coverage and billing requirements, he said.

That apparently has not been enough.

"The overpayments occurred," the IG concluded, "because CMS's controls were not effective in preventing payments for chiropractic services that were medically unnecessary."