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Guess Who’s Under the OIG Spotlight?

Compliance Basics
in Compliance Basics

Find out what this means for you and your practice

Chiropractic has again found itself in the OIG (Office of Inspector General) spotlight. According to OIG records, since 2010 Medicare has paid more than $450 million per year for chiropractic services. An estimated $257 - $304 million per year of this total dollar figure has been identified as estimated overpayments.

While chiropractic overpayments are not brand-new information, the OIG appears to be taking a firmer stance for accountability measures to be properly implemented by the CMS program and providers. The OIG notes minimal success in audit and recoupment efforts, and as such, places a tone of urgency in this matter moving forward. Chiropractic providers, like all healthcare providers, must be responsible for putting their best foot forward to comply with Medicare documentation and billing guidelines to minimize risk for allegations of Fraud, Waste and Abuse.

Here are the most common reasons for overpayment as noted by the OIG:

  • Medically Unnecessary services billed as though they are in fact medically necessary
  • Covered services billed using the incorrect procedure code per Medicare billing guidelines
  • Evidence of chiropractic treatment not documented
  • Chiropractic treatment and medical necessity insufficiently documented per documentation standards

As Medicare continues to discover hundreds of millions of dollars paid for chiropractic services, the OIG has handed down specific recommendations for CMS to consider implementing as measures of screening, prevention and recoupment of Medicare fraud, waste, and abuse. Among those recommendations, the OIG requests that Medicare Contractors place greater attention and scrutiny into chiropractic billing patterns and conduct more reviews through random sampling of chiropractic claims.

To further support their findings, the OIG draws attention to a few investigations conducted on chiropractic claims where fraud was clearly identified. Importantly, while most findings do not indicate fraud, the significance of penalty for findings of waste and abuse of federal programs must not be taken lightly. As always, a proactive approach is far better than waiting it out and hoping to be overlooked. Medicare consistently reports that it is not “if” a provider will be audited but rather “when”.

As the old Chinese Proverb says, “The best time to plant a tree was 20 years ago… the second-best time is today.” These words of wisdom are likely priceless when it comes to many things. In terms of minimizing your risk of audit, right now is the time to implement the following:

  1. Random chart audit to ensure documentation and coding is correct. Save your time and ask the pros. KMC University regularly conducts chart audits for many practices. We can do this for you!
  2. Utilize your KMC University Library for current guidelines and training in coding, billing, documentation and other critical categories.
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