CMS to Begin Chiropractic Services Supplemental Measures Study
What to do if your claim is selected for review
Background: On November 20, 2009 the President issued 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 programs, while continuing to ensure that the right people receive the right payment for the right reason at the right time. The executive order requires federal agencies to conduct semiannual studies to identify and reduce vulnerabilities in high risk areas. The Centers for Medicare & Medicaid Services (CMS) is conducting these studies under the Comprehensive Error Rate Testing (CERT) program.
Chiropractic services claims paid under the Medicare Part B Program were selected as an area of focus. Chiropractic services were chosen as a focus area for several reasons. Medicare pays only for medically necessary acute chiropractic treatment. When further improvement cannot reasonably be expected from continuing care, the services are considered maintenance therapy and are not payable under Medicare. A recent Office of Inspector General (OIG) study found that significant vulnerabilities exist in connection with chiropractic claims, particularly concerning Medicare payments for maintenance therapy. In addition, the 2009 Medicare fee-for-service (FFS) error rate for chiropractic services was 31.7% with $174.1 million in projected improper payments. The primary causes of the errors were payments for maintenance therapy and missing plans of care.
The chiropractic services supplemental measure study will focus on determining whether chiropractic services billed to Medicare were medically necessary acute chiropractic treatment. For each claim selected, CMS will review medical records up to 12 months prior to the date of service on the claim. CMS will deny claims for services determined to be maintenance therapy and recoup any overpayments.
If one of your claims has been selected for review: You will be contacted by letter from the CERT Documentation Contractor (CERT DC) beginning in mid-August 2010. The letter will instruct you to provide the CERT DC with the previous 12 months of medical records for the identified beneficiary. Failure to respond to the medical records request letter within the specified time period of 30 days will result in a full denial of the claim, as well as a possible fraud referral. The universe for the initial phase of this study includes beneficiaries with multiple claims from the same chiropractor in the sample months (April 2010-June 2010). A random sample of 100 beneficiaries was drawn from this universe.
CMS urges all chiropractors who receive a letter for this chiropractic services supplemental measure study to respond to the request for medical records immediately upon receipt of the letter.
Results: CMS will report the
results of this chiropractic services supplemental measure study in March
2011 and then semiannually thereafter. The reports will be posted on CMS'
public website at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/index.html
. For
more information about the chiropractic services supplemental measure study,
please contact Jill Nicolaisen at 410-786-5873 or Jill.nicolaisen@cms.hhs.gov.
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