Why Am I Suddenly Getting Reviewed by Medicare?


I have heard this question a lot as I consult with chiropractors all over the country. In a discussion with one doctor, he stated that six years ago he had been reviewed with no problems or errors. He was reviewed a few months ago and had a 100% error rate. The puzzling part was that he hadn’t changed his documentation system in that time. The documentation that was 100% OK just six years ago was now 100% wrong. What happened?

Two things happened. One: Medicare has better defined what they expect from chiropractors regarding documentation; and Two: Medicare is required to maintain budget neutrality.

In 2003 and 2004, Medicare made several revisions to Chapter 15, Section 240, of the Benefit Policy Manual. Section 240 details Coverage of Chiropractic Services and includes information about what documentation Medicare expects on initial visits and subsequent visits. With this information in hand, reviewers have been better able to define what Medicare expects from chiropractors regarding their documentation.

Medicare has been mandated by law to maintain budget neutrality. The Centers for Medicare and Medicaid Services use a complex formula to calculate the Physician Fee Schedule. This formula uses a Conversion Factor (CF) expressed as a dollar value and adjusts it using a Work Relative Value Unit, a Practice Expense Relative Value Unit, a Malpractice Relative Value Unit, a Work Geographic Practice Cost Indices, a Practice Expense Geographic Cost Indices and a Malpractice Geographic Practice Cost Indices. Confused? Don’t feel alone.

If it helps, the formula looks like this: [(Work RVU x Work GPCI) + (PE RVU x PE GPCI) + (MP RVU x MP GPCI)] x CF.

I don’t know about you, but I’m as confused as ever. What is important to note is that CMS can change any value or combination of values in this formula and cut our fees. “Section 133(b) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) required that the Secretary of the Department of Health and Human Services apply the required budget neutrality (BN) adjustment to the CF (conversion factor) beginning January 1, 2009, instead of continuing to apply the BN adjustment to the work RVUs required as a result of the Five Year Review of Work.” The Medicare Physician Fee Schedule Conversion Factor at the time of the writing of this article is $36.0846.

So, what does this mean to you, the doctor, trying to make a living by helping other people? It means that Medicare is watching you closer than ever. The reality of the situation is that Medicare must provide services to an ever-increasing pool of beneficiaries without spending more money. They will accomplish this by increasing premiums, increasing deductibles, and recovering “overpayments” to doctors and other providers. Medicare’s definition of an overpayment is any payment that has been made to a provider that is not supported by the documentation in the patient’s chart.

http://www.theamericanchiropractor.com/images/shortissue6.jpgMedicare has arrayed a mighty horde of contractors and subcontractors to ensure that no overpayment is missed. Everything from the new Recovery Audit Contractors (who are paid on commission) to the newly re-named Zone Program Integrity Contractors to the reviewer at the local Medicare Administrative Contractor are there to ensure that payments are made only for medically necessary services. If the documentation does not prove that the services were medically necessary, then they weren’t and you owe Medicare some money.

The scope of this article is not to give you all of the details of the various Medicare contractors and how they will review you, but rather to make you aware Medicare has greatly increased their efforts to collect money from you.

Concerning Medicare, what worked ten years ago or even five years ago isn’t good enough today. When you hear the stories about the doctor that had to close his practice and file bankruptcy because of Medicare reviews or the doctor that Medicare is attempting to collect $1.5 million from, believe them. I know for a fact that these stories and countless more like them are true. Your best defense is to update your Medicare protocols and keep them current. Strongly consider implementing an office compliance program. If you don’t know what that involves, then hire a consultant that does. It will be money well spent.

Dr. Ron Short is a certified Medical Compliance Specialist, a certified Peer Review Specialist and a certified Insurance Consultant. He consults with doctors regarding Medicare and office compliance programs as well as presenting seminars on Medicare, documentation and compliance. You can send your question or comments to Dr. Short or join his mailing list at [email protected].


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