April 2006

Medical audits target chiropractors

by Dr. Jeffrey Shay

Recently, I received phone calls from five doctors who are being audited by their regional Medicare carriers. This is not unusual in itself. I've seen a series of audits performed in past years by regional carriers in Iowa and other states. What makes these different is that they appear to be occurring in a large number of states simultaneously. Even worse, some of the doctors who called me also related stories about other acquaintances being audited in yet more venues. It appears that no chiropractor meets the standards (at least none that I'm aware of), and the fines assessed against them are larger than in the past...much larger.

So what's going on? Is Medicare simply doing its job, or is there an ulterior motive? Are chiropractic records that bad, or are the reviewers using unfair standards? Are chiropractors being targeted by Medicare, or does the profession have a persecution complex?

Let's look at the facts.

First, Medicare does have a responsibility to its constituency to ensure that treatments by any practitioner are both necessary and cost‑effective. The regional Medicare carriers have an obligation to set standards and see that they are being followed.

However, the standards should be fair and by definition based on the realities of the profession being audited. In this case, the real point of contention is whether chiropractors are being judged by real chiropractic standards (not to mention real chiropractors), or whether questionable standards are being used. Also, if irregularities exist, does the punishment fit the crime or are we being used to cover the national trade deficit?

There is some reason to believe that there's more to these audits than just a few doctors who can't get their notes right.

First, CMS (Medicare's official name) is admittedly suffering from severe financial problems, which are worsening into the future. This would seem to prod carriers toward taking measures that would ameliorate payments and place limits on services being covered.

Second, Medicare officials have often complained about faults existing in chiropractic recordkeeping, and have recently used this excuse to propose further cuts in chiropractic coverage.

Third, don't forget about the ACA‑sponsored legal action filed against Medicare for allowing private programs to eliminate chiropractic coverage by substituting another type of practitioner to do manipulative services. At this point, I'm not criticizing their court action, but merely pointing out that it exists and is probably a thorn in Medicare's side.

With all the recent audit activity by regional carriers, it would do well to remember that, with the exception of a limited test program, chiropractors are only paid for one service: spinal manipulation. We have always been subjected to severe cost controls, and payment for chiropractic services amounts to just a little over one percent of Medicare costs.

It makes one wonder why Medicare would concentrate on audits searching for so‑called "unnecessary" services by doctors being paid the Medicare version of a minimum wage. Note that this comes on the heels of articles in Business Week and other national publications questioning the need for most bypass surgeries and back operations. These are expensive procedures, but the folks at Medicare seem more concerned about analyzing the need for adjustments.

All in all, there seems to be little here to believe that Medicare wants to continue covering chiropractic services.

Make no mistake about it, we are prime targets for Medicare audits for two reasons. To start with, these audits are conducted by non‑chiropractic personnel, viz, nurses. They have neither a love for our profession, nor an understanding of its standards. There are, of course, chiropractic consultants, most of whom use standards that are medically oriented, and have the same relationship to the carriers that Igor has to Dr. Frankenstein. This brings up one other problem, namely that there is no widespread agreement on audit standards, i.e., what the records should contain.

Although I've asked carrier representatives for figures comparing audits among the various professions, they have never provided them. This information appears to be as closely guarded as the location of Bin Laden's cave. It would lead one to suspect that we're not being treated on an equitable basis, which isn't exactly breaking news if you've been around our profession for more than an hour.

It should be noted that the fines seem to be worsening. Recent reports indicate that fines ranging from $93,000 to $131,000 are becoming commonplace. Such penalties are not just punitive; for most chiropractors they are lethal. Not many practices could survive a fine this massive. In the past, CMS has often penalized doctors by confiscating payments for patient visits performed over a period of three years. Now they've increased this to four years. Another oddity is that one doctor was given a modest fine after a limited audit. He paid the penalty, only to be audited again a month later.

Who are these doctors and what have they done? In most cases, they were selected for having a higher visit profile than average. They didn't rob a bank or steal from a convenience store or put explosives in their shoes and jump in an airplane.

Often, there's a presumption these doctors probably "did something" and weren't practicing like the honest ones (read that to mean "the rest of us"). This attitude is naive. More and more doctors are being caught in this net, and most are guilty of nothing more than treating patients. Maybe their records didn't pass muster, but the really bad news is that nobody seems to pass. In this respect, the audit process appears to be little different than the Spanish Inquisition.

One problem is that most audits have only two outcomes ‑‑ all good or all bad. This encourages punitive reviews such as the ones we're now experiencing.

There should be some middle ground between these extremes, as there is in most things in life. What if the doctor could only be fined for a portion of the notes that are insufficient, say 10%? You can bet that the audit levels would drop drastically, because they would not be as profitable for the carrier. How could a carrier demand recovery of payments over three years because the doctor forgot to enter lumbar ROM findings? It's much easier to declare that the records do not support treatment and demand they refund all the money they have in the bank.

The WCA is taking action about this as my column is being written. I forwarded the audit information to Dr. Rondberg, who has already brought the matter to the attention of several legislators, as well as some other contacts. This issue will obviously be brought up at the Chiropractic Coalition meetings in May. We intend to require chiropractors to be judged by our own professional standards and by people who adequately represent the profession. Having nurses review chiropractic claims is comparable to having Dick Cheney teach firearms safety courses.

We're also working on other recommendations to help chiropractors who get snagged in this web.

The profession needs to understand that doctors targeted by Medicare have not necessarily done anything wrong. They were just the first of us in line.

(Dr. Jeffrey Shay, a graduate of Palmer College of Chiropractic and the WCA's 1996 "Chiropractor of the Year," is the World Chiropractic Alliance Director of Insurance Relations. He welcomes comments or questions regarding any insurance‑related subject appearing in this column. Dr. Shay is available to speak to your state or local organization. Contact him at 1501 Mulberry Ave., Muscatine, IA 52761, or the WCA offices, FAX 480‑732‑9313.)