According to the results of a dismal third quarter report by Railroad Medicare (administered by Palmetto GBA), chiropractors will continue to be audited through the 4th Quarter of 2014 due to a high error rate.  Palmetto’s latest audit investigation revealed that 79.5% of chiropractic claims were submitted incorrectly and therefore, did not merit any payment.

Although Palmetto’s findings were spread over several categories, their analysis pointed out some specific problems with chiropractors’ treatment plans that could be causing some significant trouble.

The Bad News About Medicare’s Investigation

Unfortunately, the first bit of bad news about this latest Medicare investigation is the fact that our poor performance is not new. Railroad Medicare conducted a previous payment review of chiropractic service claims at the end of 2013 with similarly lackluster results ( a 77% error rate was found in that chiropractic audit review, which I also reported on).

Additionally, the fact that these audits are being conducted by Railroad Medicare (via Palmetto GBA) doesn’t help the profession at large.  It would be one thing to say that all the docs in one state are ignorant, doing things incorrectly or slow-learners.  But Railroad is a nationally based program.  So the finger of blame is pointing at all of us.

Another painful blow was that these audits were pre-payment reviews.  Pre-payment reviews essentially happen when the claim arrives at the payer.  They are denied and no reimbursement is given.  If you are a PAR provider with Medicare, this means you don’t get paid.  If you are NON-PAR, it means that your patient does not get reimbursed.  Either way, though, you’ve already done the work.

Here’s the Good News

One of the most (or only?) likeable things about Medicare is that they publish a lot of bulletins, guidelines and updates.  Most chiropractors and their staff don’t read them, but…the info is definitely out there. True to form, this latest review produced a bulletin that gives some great details about exactly where we are going wrong in the Medicare documentation arena.  You can view the full bulletin here.

Below are the highlights in respect to Treatment Goals:

 How Your Chiropractic Treatment Goals Should Be Structured

According to Medicare guidelines, here is how your treatment goals should look:

  • When developing goals identify the Problem(s) your care is attempting to correct
  • Be sure to address ADLs that are a result of that problem
  • Establish a baseline for that problem
  • Set a goal that is individualized to the patient’s needs.
  • Progress towards goals should be demonstrated in objective manner, rather than conclusory terms.

Treatment Plan Goals Examples From Medicare

Example 1: A patient presents with pain at a level of a 9 on the Visual Analog Scale (VAS). Given the patient’s history, functional assessment, current limitations, et cetera; it is reasonable to expect that pain can be reduced to a 3 through treatment. Your goal becomes to reduce pain from 9 to 3 on the VAS.

Example 2: A patient that presents with the ability to stand for only 20 minutes due to pain. Throughout the course of treatment, the patient will be able to stand for longer periods of time. Based on the patient’s history and your assessment, an acceptable goal would be for the patient to be able to stand for more than an hour without pain.

In the examples listed above, the VAS pain scale and standing time are objective measures that will show progress towards specific goals as opposed to simply concluding that the patient is doing “better” since the onset of care.

Conclusion – What to Do Next

Sadly, many chiropractor don’t even include Goals in their Treatment Plans and, truthfully, they are missing the other required elements of a treatment plan as well.  (thus the high error rate).

If this is you, fix it fast.  As evidenced by Medicare’s negative pre-payment reviews, it only takes one missing item for them to deny your care.  Worse, if you repeatedly fail broad-scoped pre-payment reviews (aimed at the profession at large), your carrier may choose to put your office on a specific pre-payment review.  What happens next is like a bad virus attached to your Tax ID.  Every claim that comes out of your office is flagged and then sent over to one of the crankiest subsets of humanity (aka auditors) for their inspection.  If they are having a particularly bad day, just about anything gives them ample excuse to deny your services.  Even on a “good day” being put on pre-payment review produces a barrage of moving targets which you must hit to earn payment.  One day your claims are denied because your Treatment Plan is off-kilter.  The next, they don’t like your Objective findings.  Next, auditors failed to find your any progress in your patient’s condition.  And so on.

1.  Take the suggestions in the above article and begin to fix your Treatment Plan Goals ASAP.

2. Review the Chiropractic guidelines provided by your Medicare carrier to meet other criteria