On Nov. 20, 2009, President Obama signed Executive Order 13520, Reducing Improper Payments and Eliminating Waste in Federal Programs, which covers many federal programs including unemployment insurance, supplemental security income, and Medicaid and Medicare fee-for-service, to name a few. During a teleconference on June 15 of this year, CMS and Comprehensive Error Rate Testing (C.E.R.T.) contractor AdvanceMed revealed that four services would fall under enhanced scrutiny as a result of Executive Order 13520: power wheelchairs, short hospital stays, pressure-reducing support surfaces and chiropractic services.
Error Rates: An Ongoing Concern
These four service categories represented the highest error rates in Medicare fee-for service. The enhanced scrutiny, referred to as a Special Studies review, will continue until the chiropractic error rate falls below the national average error rate, which was 12.4 percent last year.
The error rates for chiropractic vary state by state. For example, Illinois has a C.E.R.T. error rate of 23.77 percent, while Colorado has a combined C.E.R.T., OIG and Trailblazer error rate of 99.8 percent. Over half (57 percent) of the Colorado error rate is the result of doctors not responding to the request for records.
The CMS Special Studies Review
The Special Studies review will randomly select 100 Medicare beneficiaries that had at least one claim from the same chiropractor in the months of April, May and June 2010. CMS will request all records for the previous 12 months for the selected beneficiaries. Unlike a regular C.E.R.T. request, to which you have 75 days to respond, you will have only 30 days to respond to a Special Studies records request. If you do not respond, that claim will be considered in error and will increase the error rate for you personally and for chiropractic as a whole.
If you have a patient chosen for the Special Studies review, you will receive a records request letter with four sections: a cover page, a page of instructions on how to submit the records, a documentation pull list and a fax cover letter with a large bar code on it. If you receive a request for records, immediately pull the requested records and review them to ensure that all available information is there. Do not change, delete or add any information. Fax or mail the records as directed. Do not send the originals if you are mailing the records.
The results of these reviews will be reported in March 2011, and reports will continue to be issued on a semiannual basis. Remember, these reviews will continue until the error rate for chiropractic falls below the national average.
With chiropractic chosen for special attention, you may be asking yourself two questions: how did this happen and what do we do about it? Let's take these one at a time.
How Did This Happen?
This happened because we, as a profession, have had one of the highest percentage error rates of all provider types for every year since CMS started the C.E.R.T. program in 2003. In the first C.E.R.T. report released in 2003 we had the highest compliance error rate at 30.6 percent. In mid-year 2008, the last report available, we had a compliance error rate of 30.2 percent, the third highest. Looking at those statistics, we have made virtually no improvement in five years. When Medicare sees statistics like that, it sees us as a problem that needs to be fixed. Since we don't seem to be doing it ourselves, Medicare is taking it upon itself to do it for us.
The health care act has new screening and compliance provisions regarding Medicare that can be implemented selectively for provider types at high risk for fraud and abuse. (See "Health Act Includes Changes to Medicare Enrollment" in the July 15 issue for more details.) Because we are under Special Study, I expect these provisions to be implemented for chiropractors at the earliest possible opportunity, perhaps by the end of the year.
What Do We Do About It?
We, as a profession, need to get serious about Medicare, because it is here to stay. The only way that we will be able to provide our services to the people who need it the most is to learn the laws, rules and regulations of Medicare and to implement the protocols that will enable us to comply with those laws, rules and regulations.
We can meet this challenge and prevail. In 2003, physical therapy was second worst with a 29.4 percent error rate. In 2008, it was 25th with a 17.8 percent error rate. Chiropractic can accomplish this sort of improvement, too, by establishing Medicare compliance as our highest priority over the next two years.
It is up to you the doctor, the consumer of information, to educate yourself on proper documentation, and implement appropriate protocols in your practice to ensure compliance. That means when your state or national association offers a seminar on Medicare compliance, you need to attend, and if they are not offering any, you need to request that they do so. Collectively, we need to step up and get it right. Doing so will go a long way to earning the respect we deserve as doctors.
