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Opting Out

medicare-card.jpgThis last week I became aware of two aspects of chiropractic and Medicare that are sobering, to say the least.

The first came as an email from one of the state chiropractic organizations promoting membership in a chiropractic advocacy group to influence the direction of the national health care debate. Ostensibly, to make sure Congress doesn’t limit access to chiropractic, while also expanding the coverage of services offered by chiropractors that are reimbursed by Medicare.

The other was a 36-page document from the Office of the Inspector General entitled, Inappropriate Medicare Payments for Chiropractic Services dated May 2009. Since many believe that the so-called health care reform will be an enlargement of Medicare, I thought it wise to read this document and get the general mood of the legal arm of the Department of Health and Human Services.

One of the major findings of the report is that as recent as 2006 Medicare inappropriately paid chiropractors $178 million for chiropractic claims. Inappropriately, meaning that almost half (47%) of the claims that they studied were seeking payment from what they call “maintenance therapy” and that the chiropractic intervention “didn’t provide a reasonable expectation of recovery or functional improvement.”

Oops.

There were other problems. Poor documentation, inappropriate upcoding, lack of a treatment plan and other basics related to justifying one’s “doctoring.” But it was the large number of chiropractors attempting to deliver a supportive lifestyle intervention within a system set up to deal with short-term episodic treatment of symptoms that seems to have caught the ire of the Inspector General.

The section on suggested recommendations begins on page 18. Not surprisingly, one recommendation is to withhold payments to chiropractors pending a review of their claims when required documentation is missing, along with a form of “profiling” in which a prepayment review is conducted on all claims from chiropractors with a history of failing to meet documentation requirements.

I prefer to believe that what the lawyers consider “inappropriate” or even “fraud” among chiropractors is either ignorance, philosophical differences or a combination of both. Unfortunately, either way it will be expensive for individual chiropractors and, in light of the current posturing for a piece of the government-run system of so-called health care, expensive in terms of the limited political capital available for the profession in Washington.

But then, I’m not in favor of chiropractic being included anyway. (You can read my rationale written just over two years ago here. In fact, rather than petitioning decision makers in the hopes of avoiding the need for a medical doctor referral, I’d recommend focusing lobbying efforts on a far more practical goal: for chiropractors to have the option (like medical doctors) to opt out of the system.

In light of the recent findings by the Office of the Inspector General, it just might be an achievable goal.

Comments (7)

J. Musker:

It would be great to see Chiropractic have full inclusion in Obamacare. However, the likely model will be Medicare and that's not looking very promising. With a 30% fee reduction on the horizon, it will be even less cost-effective to be a provider. And why are we not 'allowed' to opt out? As another comment mentioned, in Canada (Ontario to be specific), Chiropractic underwent a series of fee reductions before being delisted. It would not be surprising if a significant reason that occured was that Chiropractic was considered a non-essential service (duplicated by other providers such as DO's and PT's). Why then are we so zealous to purge our roots and differences (subluxation/adjustment). Is it foolish to believe duplication will not lead to elimination?

I agree. I have tried to get out of Medicare for these reasons, but much to my surprise, it appears I cannot. So I have just stopped taking Medicare patients. Even though I am not a provider, I am supposedly still bound by Medicare rules and fees and I cannot receive coverage from secondary insurance policies. It's a ridiculous situation, which will be compounded by 1000 when socialized/nationalized/federalized/demoralizedhealth care takes over...

IF (and that's a big IF) chiropractic is covered in the new scheme it will be Medicare-like. Later, when budgets get tougher, they may choose to decrease the reimbursement or "de-list" it altogether, like they just did in one Canadian province. Those that hold up Canada or the UK as a model should heed that example. They can give it to you and they can just as easily take it away.

Bryan Siegel, DC:

Well said Tim, I fully agree. This system is twisted and manipulative; for chiropractors to want to even participate in this is ridiculous. We need to stand strong and get back to the basics...fee for service, patient/doctor.

By the way, that medicare document is such a joke, this is another example where there are so many problems with a third party paying for care. Their primary focus is how to cut costs, but what about the people that paid into the Medicare system their whole life? It is ok for the government to borrow from Medicare but when the patient actually wants to use the benifits for Chiropractic that they want and paid into their whole life-- Medicare is going to do post payment audits and intimidate the providers that they seek care from? Medicare acts like patients are victims and the chiropractors are somehow twisting their arm to force them in the office. Don't patients get to choose chiropractic if they want? Can't they choose to come in or not come in? What about the ACA study that shows that patients under chropractic care cost less money overall for medicare than the ones not under chiro care? This whole thing is a joke-- Do us a favor and eliminate chiropractic care from medicare, if the public wants chiropractic in medicare let them fight for it, if not then let them pay for it.

Rather than medicare doing witch hunts for chiropractors and judging them on an inaccurate model, they should just make some standards and cover within those and let the patients take care of the rest out of pocket-- This would save stress, manpower, paperwork and money. Then we do not have to have debates over what phase of care the patient is in and can just focus on getting them better.

Todd Hackney:

While I agree with the premise of your blog, the problem will still remain that if people (ie-patients) are going to allow their insurance companies to dictate how they care for themselves, those people will ALWAYS choose the "path of least resistance" and those physicians who are "in network". It's just that simple....IN network typically means less money out of pocket and less responsibility for the patient. OUT of network, at least from what I've seen some "ingenious" (read: unscrupulous) DC's do, means MORE money out of pocket, MORE time wasted in the waiting room, MORE time spent mailing the DC insurance payments for over-utilization and LESS time actually being treated by the DC even though they're in the office 2 or 3 times per week for months!

Bryan Siegel, DC:

Great blog Bill; looks like more and more opportunities are presenting themselves for chiropractors to become undomesticated! Relying on Medicare and the likes has, as you said, tamed the essence of the chiropractor. I just saw a quote by Donald Trump and thought it was worthy to mention here: "Your higher self is in direct opposition to your comfort zone." Looks like the chiropractic profession is being pushed out of the comfort zone.

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From May 26, 2009 7:07 AM

This page contains a single entry from the blog posted on May 26, 2009 7:07 AM.

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