Chiropractic Medicare Forms and Documentation

Unlike medical doctors, chiropractors may not “opt out” of Medicare. Electing to be a non-participating chiropractic Medicare provider is not the same as opting out. And being a non-participating provider does not exempt you from having to bill Medicare, nor does it change your documentation requirements.

(Check out the Patient Media Medicare brochures in both Par and Non-Par versions, plus the Medicare Worksheet to help seniors understand how your first-visit charges are computed.)

Medicare comes with a serious responsibility for every chiropractic practitioner and his or her team. Not only must you know, but you must follow, the rules and regulations governing Medicare. If chiropractic care is done incorrectly it can result in charges of fraud, a potential felony conviction, fines and even jail time.

While Medicare compliance is important, it is a vast subject beyond the scope of this short article. However, there are two common Medicare mistakes chiropractic professionals routinely make.

Medicare and “Financial Inducement”

Simply put, any type of “inducement” is strictly forbidden.

The relevant statute makes it illegal to offer, pay, solicit or give anything of value as an incentive to encourage chiropractic care for which Medicare (or Medicaid) will be responsible. This applies to waiving certain fees for Medicare chiropractic patients, even those with a genuine financial hardship.

Understandably, seducing chiropractic Medicare patients with discounts or other inducements may result in one or more of the following concerns:

Increases costs.  When gifts or free services are offered in the hopes of influencing patient behavior, it can raise costs, reduce quality or both.

Needless services. The cost of the inducements may be offset by providing unnecessary services or reducing the time spent with the patient.

Unfair disadvantage. Gifts or discounts would tend to favor larger practices that often have greater financial resources, putting smaller practices at a disadvantage.

Some of the more common examples of financial inducement that could lead to accusations of fraud or abuse include:

  • Offering to waive deductibles or copayments
  • Free X-rays or free spinal examinations
  • Offering free or discounted noncovered services (i.e. therapies)
  • Coupons offering reduced examination fee
  • Routine use of “Financial Hardship” arrangements

Acceptable marketing overtures may include small, inexpensive gifts (but not cash) or services. What’s considered inexpensive? Gifts or services with a retail value of no more than $10 individually, and no more than $50 in a given year. In other words, it’s probably not worth the trouble!

Chiropractic Medicare Maintenance Visits

Another aspect of Medicare that seems to have the greatest misunderstanding (and potential for an audit) among chiropractors is how maintenance care visits are handled. Denials due to a lack of "medical necessity" are far too common.

Maintenance is defined as a treatment plan that seeks to prevent disease, promote health, prolong or enhance the quality of life, or is performed to maintain or prevent deterioration of a chronic condition. Once the chiropractic care becomes supportive rather than corrective, it’s considered maintenance.

Although maintenance care is “covered” it’s not “reimbursable” because it’s not deemed as reasonable and necessary according to Medicare. Only acute and chronic services are considered active care and subject to reimbursement. A provider must submit a claim for all covered services regardless of whether they are reimbursable, using proper modifiers.

Each visit must be medically necessary and there must be sufficient objective proof that the patient’s condition is enhanced. Once further improvement cannot be reasonably expected, the treatment is considered supportive or preventive and Medicare will not reimburse.

Chiropractors and the Office of Inspector General

In May of 2009, the Department of Health and Human Services’ Office of Inspector General (OIG) published a report entitled “Inappropriate Medicare Payments for Chiropractic Services.”

It did not paint a particularly complementary picture of chiropractic. In fact, it amounted to a warning shot that a more critical eye will be given to chiropractic claims in the years ahead:

  • Medicare inappropriately paid $178 million for chiropractic claims in 2006.
  • Efforts to stop reimbursement for maintenance care had been ineffective.
  • Chiropractors often do not comply with the Medicare Benefit Policy Manual documentation requirements.

These findings mean that in the future you can expect:

  • Stricter policies to prevent payments for nonsymptomatic care.
  • A greater focus on treatment episodes rather than individual claims.
  • Increased scrutiny of documentation and record keeping.
  • Harsher penalties for medically unnecessary and miscoded claims.

It’s time you bring your documentation into compliance. Use the correct documents, record the proper information and prove medical necessity. Implement a Paperwork System and get the proper training to use it correctly.