The Office of Inspector General's (OIG) mission is to protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries.  They are dedicated to combating fraud, waste and abuse and to improving the efficiency of HHS programs, such as Medicare.  The OIG releases a Work Plan that sets forth various projects to be addressed each year.  Here are the excerpts from 2016 that pertain to chiropractic.

Chiropractic services—Part B payments for noncovered services

"We will review Medicare Part B payments for chiropractic services to determine whether such payments were claimed in accordance with Medicare requirements. Prior OIG work identified inappropriate payments for chiropractic services furnished during CY 2006. Subsequent OIG work (CY 2013) also identified unallowable Medicare payments for chiropractic services." 

Chiropractic services—Portfolio report on Medicare Part B payments

"We will compile the results of prior OIG audits, evaluations, and investigations of chiropractic services paid by Medicare to identify trends in payment, compliance, and fraud vulnerabilities and offer recommendations to improve detected vulnerabilities. Prior OIG work identified inappropriate payments for chiropractic services that were medically unnecessary, were not documented in accordance with Medicare requirements, or were fraudulent." 

In the work plan, the OIG also reminds us of the following points:

  • "Part B pays only for a chiropractor’s manual manipulation of the spine to correct a subluxation if there is a neuro-musculoskeletal condition for which such manipulation is appropriate treatment." (42 CFR § 410.21(b).) 
  • "Chiropractic maintenance therapy is not considered to be medically reasonable or necessary and is therefore not payable." (CMS’s Medicare Benefit Policy Manual, Pub. No. 100-02, Ch. 15, § 30.5B.)
  • "Medicare will not pay for items or services that are not “reasonable and necessary.” (Social Security Act, § 1862(a)(1)(A).)  (OAS; W-00-13-35606; W-00-14-35606; W-00-15- 35606; various reviews; expected issue date: FY 2016)
  • "CMS’s Medicare Benefit Policy Manual, Pub. No. 100-02, Ch. 15, § 240.1.2 of the manual establishes Medicare requirements for documenting chiropractic services. This planned work will offer recommendations to reduce Medicare chiropractic vulnerabilities detected in prior OIG work." (OAS; W-00-16-35770; OIG-12-14- 03; expected issue date: FY 2016) 

Basically they are saying that every time they look at DCs they find problems.  So, they will keep looking at DCs.  In the bullets above they outline the resources that explain what you need to know to avoid becoming one of these problems.  ChiroCode has summarized all of this information in an easy to read format in chapters 3 and 4 of the 2016 DeskBook.  You should also track down your Local Coverage Determination from your Medicare Contractor.  If you need even more help, consider ChiroCode's Premium Membership.