September 2003

An open letter to the profession regarding HR2560

by Adam J. Magary, Chief of Staff, Rep. Donald Manzullo

Despite any rumors that may be circulating, Mr. Manzullo has absolutely no intention of withdrawing his legislation. While we have always been and continue to remain open to constructive suggestions for improvement, Mr. Manzullo has not seen any arguments against the bill that warrant any action beyond technical corrections.

The differences that now exist between supporters of the legislation and opponents of the legislation are purely philosophical in nature. This legislation may inconvenience certain chiropractic philosophies, but it will not devastate chiropractic as a whole.

Mr. Manzullo remains committed to the idea that chiropractors are equal, but unique. He remains committed to the idea that chiropractors who participate in Medicare should be reimbursed for the use of their chiropractic services‑and that this reimbursement should go beyond just the manipulation procedure itself; chiropractors should be also be reimbursed for x‑rays, examinations, and the use of instrumentation.

Mr. Manzullo remains committed to the idea that a chiropractor and not an office‑based bureaucrat is the best one to determine the necessity of the care. Mr. Manzullo remains committed to the idea that chiropractors should not have to fear reimbursement denials which are subject to the whims of office‑based bureaucrats who deny claims based on financial necessity not medical necessity.

He especially is outraged that it looks like little is being done within the federal government to correct the perception that if a carrier denies a claim for a service that was actually rendered (and necessary according to the chiropractor's documentation), the federal government still regards and treats that chiropractor as having committed fraud. Just two weeks ago, we discovered that chiropractors have popped up on the radar screen of the Office of Inspector General.

The OIG has been randomly auditing chiropractors around the country with the hopes of determining how much "fraud" or maintenance care is being billed to Medicare. How much longer should chiropractors have to fight to get paid for claims that were denied without the carrier even reviewing the tests and documentation justifying the care? Does that not seem absurd to anyone (that they say the service is not medically necessary but they do not look at the x‑rays that objectively demonstrate the existence of a subluxation)?

In my seven years on Capitol Hill, I have found that few in the federal government even understand what chiropractic is. That is because there has never been a clear definition of what chiropractic is. Whenever Congress becomes convinced enough that chiropractic is a good thing and votes to expand it as a benefit to federal beneficiaries, a massive regulatory subluxation occurs because the few regulatory personnel with any background in health care come from a medicine‑based, chiropractic‑suspicious education. The rest don't have a clue what chiropractic is and quite frankly, don't care what chiropractic is.

To them, chiropractors are just another bunch of whiny doctors who only care about getting more cash‑and unfortunately, there are those in the profession who help perpetuate that perception. This is the segment of the chiropractic profession who wants to have its cake (and everyone else's cake) and eat them both, too. They want to be able to seek reimbursement in other providers' backyards, but then sue the government to keep those same providers out of their own backyard. I don't see how you can have a generic and fully‑blended definition (such as physician) and not have all services be up‑for‑grabs.

Let me state emphatically, in no way is Mr. Manzullo in favor of lower reimbursements for chiropractors and disputes the claims of bill detractors that his legislation would do that.

It may be true that reimbursements for some codes may be lowered because of non‑physician status, but Mr. Manzullo's legislation adds reimbursement in areas that chiropractors never received reimbursement for before. And regarding the reimbursement that is lowered, does it seem right that a chiropractor would be reimbursed through Medicare for malpractice insurance at the same level as another provider whose malpractice insurance costs him $200,000 rather than $2,000?

Mr. Manzullo's legislation eliminates the need for OIG's, CMS's, and WPS's to invade chiropractic practices to confiscate records that may contain maintenance care. Those chiropractors who have never had the pleasure of this experience better keep their fingers crossed that their number does not come up in the lottery.

Mr. Manzullo's legislation eliminates the whole concept of maintenance care and instead establishes a clinical necessity standard. Objective clinical evidence provided by a chiropractor will be enough to justify the care.

While CMS and OIG will still be and should be on the prowl for bad actors, the elimination of the maintenance care prohibition will provide another stream of reimbursement for chiropractors, and at the same time, remove the fear that the feds will park a "fraud patrol" van in front of your practice and send letters to all your patients informing them that you bill Medicare for medically unnecessary services.

While Mr. Manzullo's legislation expands the reimbursement streams for chiropractors, he remains concerned that reimbursement‑only strategies do not address any of the concerns I have described above.

Reimbursement‑only strategies do not get the federal government off the backs of honest chiropractors. If anything, they invite greater scrutiny. Reimbursement‑only strategies do not address bureaucratic disputes over what care is necessary. Reimbursement‑only strategies do not address medical specialties that claim similarity with chiropractic or those who wish to eliminate chiropractic all together. Reimbursement‑only strategies fail to plan for the notion that what is given can readily be taken away.

Formulas will always be adjusted to favor the payer. But once you determine that chiropractic includes x‑rays, examination, and instrumentation, how easy is it to take that away? Those items are key pillars of the provision of chiropractic and not as easy to dismantle as a short‑lived gain in a formula. That is why Mr. Manzullo felt it was necessary to finally create a section in the Medicare statute that actually reflects and protects what chiropractic is and what chiropractors do.

Based upon the concerns that Mr. Manzullo has about the future of chiropractic (especially with the OIG preparing to launch on the profession), Mr. Manzullo believes his legislation is critical now more than ever.

Mr. Manzullo has not received any substantive, non‑philosophical criticisms of his legislation, and therefore has no reason to believe that abandoning H.R. 2560 is the right thing to do. While he recognizes that serious philosophical rifts occur within the chiropractic profession, his main objective is to see that his constituents continue to receive the services that were promised to them (chiropractic being one of them), and that chiropractors who volunteer to participate in federal programs are treated fairly by the federal government.

A strong, clearly‑defined chiropractic statute is vital to protecting both chiropractors and patients. H.R. 2560 may not be perfect, but it is a pretty solid foundation upon which to begin rebuilding and redefining chiropractic. As with all parties interested, please do not hesitate to pass along to me any concerns, suggestions, or questions about Mr. Manzullo or H.R. 2560.