What payers should know about chiropractic fraud, waste and abuse

FierceHealthPayer: Anti-Fraud spoke to Daniel S. Bowerman, D.C., to learn about chiropractic fraud and overutilization. Bowerman (pictured) has been a practicing chiropractor since 1978. He's a principal at Expert Opinions Consulting in Philadelphia, which provides expertise in civil and criminal proceedings, and he served as a health plan medical director for 13 years.

FierceHealthPayer: Anti-Fraud: What are some of the major schemes run by rogue chiropractors?

Dan Bowerman: Many emerging schemes are recycled problems, and they follow reimbursement. Services that pay a nominal amount tend to be billed excessively. One example is billing for the American Medical Association's Current Procedural Terminology code 98943, extra-spinal manipulation. Utilization of this code has become a national endemic in the last eight years.

This procedure involves the shoulder, wrist, elbow, knee or ankle. Providers began billing this code in addition to regular manipulation charges to generate higher allowances. Strictly speaking, you don't expect to see billing for both these codes for every patient at every visit.

I've also seen claims for services not rendered or services that don't meet reimbursement thresholds. Then there's unbundling, or billing for component parts of an evaluation on separate days.

Upcoding is a problem. We see the highest levels of services frequently claimed for manipulation services and electrical muscle stimulation.

I've also seen misrepresented therapeutic magnetic resonance services. The device used for these services is classified by the Food and Drug Administration as a transcutaneous electrical nerve stimulation (TENS) unit. One provider billed a nonspecific code for magnetic resonance imaging and received payments of more than $2,000 per claim. Another example of misrepresented services is traction billed as surgical decompression.  

There's also misuse and overuse of services. If it takes a provider one week to get something done but billings are for three weeks to four weeks of care, for example, that's an issue. And when all patients receive the same mix of services, that's generally not considered medically necessary.

An exploding utilization problem is overuse of durable medical equipment (DME). Several vendors sell assistance in getting chiropractors licenses to become DME distributors. This can be lucrative. But DME use should be an exception, not the rule. A trend of billing for lower back braces costing up to $1,000 each has appeared.

Further, I worked on a criminal case involving straw practice ownership. The provider hired someone licensed to perform services, but that person wasn't present in the office at the time of care. There's also masked practice ownership. I testified in a case where a nonlicensed, nonclinical individual used a practitioner's national provider identifier to bill $1.8 million in claims. He was sentenced to five years in federal prison.

FierceHealthPayer: Anti-Fraud: Do you think chiropractors' limited scope of practice contributes to fraud, waste and abuse within the profession? Why or why not?

Dan Bowerman: Absolutely, since there are fewer opportunities for chiropractors to bill for services. In Medicare, for instance, chiropractors are only reimbursed for three procedures. We're not reimbursed for traditional evaluation and management, but we're expected to perform those services. Not getting reimbursed can create a kind of chip on the shoulder, and providers may use that to rationalize billing excesses.

Some providers make up for the loss in volume: I've seen some practices seeing up to 1,000 patients per week or 100 patients a day in less than eight hours.

Depending on the state, chiropractors can delegate certain services. I worked on a case where a physician was supposedly overseeing a practice. But a physician's assistant (PA) was doing trigger point injections and even facet blocks (an injection inside the joint of the spine). The doctor had never been to the office, and you wouldn't expect to see a PA perform such a dangerous procedure. Plus the PA double billed for himself and the doctor.

FHPAF: It's been said chiropractors should interact more closely with primary care providers to coordinate patient care. Yet integrated practice models00where chiropractors hire physical therapists, nurses or M.D.s to work for them--have been linked to false claims. Any comments on this?

Bowerman: It's a wonderful idea for patients to see and be able to get counsel from a wide variety of specialists. But few practices are patient-centric, meaning that treatment is minimized and outcome-focused.

In problem cases, patients are churned or shuffled from one provider to another. This cycle repeats to maximize reimbursement on each patient by providing a whole host of services the person may or may not need. Watch very carefully services such as injections rendered for pain management, neuropathy or degenerative joint disease of the knee.

FHPAF: What can insurers do to curb chiropractic overutilization? One concern is overuse of X-rays which--besides increasing costs--may expose patients to needless radiation.

Bowerman: Plans have approached overutilization differently. They've tried limiting benefits to a dollar amount or a specific number of visits, for example. But it's getting harder to do that in the wake of the Affordable Care Act. Plans also have done prepayment reviews.

I've seen significant reduction in use of full spine X-rays. Fewer chiropractors own X-ray equipment today compared to a decade or more ago. Medical providers who own X-ray units tend to use them at higher rates.

There's a safety concern with X-rays, particularly with children. I know of a case where children were subjected to six separate X-rays, when none of the children had any trauma or symptoms to warrant these studies. Children received enormous doses of skin radiation they didn't need. Beyond the problem that these films were inappropriate, many were unreadable. And there was little effort to protect the children by using gonadal shielding or narrowing the beam to a specific area.

I reviewed another case for law enforcement where a young woman said she didn't know if she was pregnant or not. The provider performed X-rays on her pelvis even though she was asymptomatic. Fortunately, her pregnancy didn't occur until a few months after these films.

FierceHealthPayer: Anti-Fraud: Please explain the difference between chiropractic spinal manipulation to remove subluxations (which may qualify for insurance payment) and vigorous back massage (which seldom qualifies for insurance payment). How can payers verify that chiropractic claims were for covered care?

Dan Bowerman: Fundamentally, the difference is medically necessary treatment to resolve a condition versus spot treatment to make somebody feel better temporarily.

Let's define what medical necessity would be for physical medicine services. Medical necessity requires the patient to have a clear, identifiable illness or injury that results in some kind of functional loss. It's also generally expected that the patient will have a treatment plan designed to correct functional loss in a time-limited, predictable fashion.

Chiropractic manipulations bring a joint through its full range of motion and then slightly beyond it. You typically hear a cracking noise as the joint releases, and that basically increases range of motion and reduces discomfort. Over time, this is expected to help resolve a specific condition.

Massage is different. It involves stretching, kneading or elongating tissue. Though massage feels good temporarily, it has no sustained long-term effect.

There are legitimate procedure codes for massage; but you wouldn't see massage in any other situation except as adjunct to other types of physical medicine services, such as exercise and manipulation. A red flag is when you see only manipulation and massage over a long period or across the entire patient population.

FHPAF: Is there anything payers can do in credentialing processes to weed bad actor chiropractors out of participating networks?

Bowerman: Payers can act to a limited degree: Verify that there are no sanctions in place against providers, for example, and that they haven't lost medical licenses. Check the national database called CIN-BAD. The federation of chiropractic licensing boards has a data mart where you can query that database to see if a provider has had sanctions in other states.

One issue I've seen is where a network provider joins the office of a nonparticipating provider. If the plan offers robust out of-network benefits, I've seen cases where patients come in to see the participating provider but all the billing comes through the nonparticipant.

I had a case where an ambulatory surgical center asked if a plan covered manipulation under anesthesia. That's been deemed experimental or investigational for the spine, and several chiropractors were trying to get in this particular facility to start performing these services.

FHPAF: Any final thoughts not covered in the above questions?

Bowerman: Properly-delivered chiropractic care can be very cost effective. And there are many good providers out there. But chiropractors don't have the same opportunities [as other providers] to make a living in nonclinical practice.

When I worked at a health plan, for example, I was one of the few medical directors for chiropractic services in the Untied States. The fewer opportunities you have to make an income providing professional services, the more you may be top heavy in terms of utilization.

Polling results have shown that few people believe chiropractors are ethical and honest. If there was less fraud, waste and abuse [within the specialty], it's likely a higher percentage of the population would seek chiropractic care. We as a profession have failed to instill faith in the public and have neglected to police our own ranks.

Editor's Note: This interview has been edited and condensed for clarity.