Medical Billing and Coding Healthcare Blog

The Centers for Medicare & Medicaid Services has announced the awarding of the next round of Medicare Fee-for-service recovery audit contractor (RAC) contracts.

The Medicare Recovery Audit Program's mission is to identify and correct improper Medicare medical billing payments through the detection and collection of overpayments made on claims of healthcare services provided to Medicare beneficiaries, and the identification of underpayments to providers so that the CMS can implement actions that will prevent future improper payments.

The new RAC contracts were awarded to:

  • Region 1 — Performant Recovery
  • Region 2 — Cotiviti
  • Region 3 — Cotiviti
  • Region 4 — HMS Federal Solutions
  • Region 5 — Performant Recovery

The RACs in Regions 1-4 will perform postpayment review to identify and correct Medicare claims that contain improper payments (overpayments or underpayments) that were made under Part A and Part B, for all provider types other than durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) and home health/hospice.

The Region 5 RAC will be dedicated to the postpayment review of DMEPOS and home health/hospice claims nationally.

The Office of Inspector General (OIG) recently released a 2016 final report on Medicare payments for chiropractic services.

In its review, OIG included chiropractic services for CY 2013 for which Medicare Part B paid approximately $438 million. On the basis of its sample results, OIG estimated that approximately $359 million, or approximately 82 percent, of the $438 million chiropractic billing payments by Medicare for chiropractic services during the 2013 reporting period was unallowable; most payments did not comply with Medicare requirements.

The OIG has attributed the improper part B payments to services that were medically unnecessary, incorrectly coded, insufficiently documented or not documented to support the billed services.

The OIG stated that overpayments occurred because the Centers for Medicare & Medicaid Services' (CMS) controls requiring chiropractors to include the -AT modifier and initial treatment date on claims were not effective in preventing payments for medically unnecessary chiropractic services. OIG claim data analysis and audit results suggest that chiropractors submitted claims with the -AT modifier regardless of whether the services were for active/corrective treatment for subluxation.

Further, chiropractors submitted claims with the initial treatment date, affirming that all required documentation was being maintained on file, even though they did not document the medical necessity of the services as required by Medicare.

Finally, CMS's education of chiropractors on Medicare requirements for chiropractic services may not have been effective in preventing payments for medically unnecessary chiropractic services.

The OIG made the following recommendations to the Centers for Medicare & Medicaid Services:

  • Determine a reasonable number of chiropractic services that are necessary to actively treat spinal subluxation and implement a system edit to identify services for review in excess of that number.
  • Determine whether there should be a limit for the number of chiropractic services that Medicare will reimburse; if so, take appropriate action to put that limit into effect, and implement a system edit to disallow services in excess of that limit.
  • Improve education of chiropractors on Medicare coverage requirements for chiropractic services and the proper use of the AT modifier to ensure that only medically necessary chiropractic services are billed to Medicare.
  • Specifically identify significant obstacles to developing a more reliable control for identifying maintenance therapy and work to establish such a control. (For example, CMS could determine a reasonable length for a chiropractic treatment episode and implement a system edit to identify services for review when the number of days between the date of initial treatment and the date of service exceeds that length.)

CMS concurred with the first and third recommendation, but did not concur with the second recommendation. Regarding the fourth recommendation, CMS stated that it had responded to the same recommendation in a prior OIG report.

After reviewing CMS's comments, OIG refined two of our recommendations. The second recommendation was refined to indicate that CMS should determine whether there should be a limit for the number of chiropractic services that Medicare will reimburse and, if so, should take appropriate action to put that limit into effect. OIG also advised CMS to consider taking other appropriate actions to put such a limit into effect.

OIG also refined its fourth recommendation to specifically address CMS's comments on the recommendation in its prior report.

Resources

Here are some helpful resources for Medicare chiropractor billing compliance:

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