U.S. Department of Health and Human Services  
  
Office of Inspector General
   
 
 
MEDICARE NEEDS BETTER 
CONTROLS TO PREVENT 
FRAUD, WASTE, AND  
ABUSE RELATED TO 
CHIROPRACTIC SERVICES  
 
 
February 
An OIG Portfolio 
2018 
         A-09-16-02042 
 
This portfolio presents an overview of program vulnerabilities 
identified in prior Office of Inspector General (OIG) audits, 
evaluations, investigations, and legal actions related to 
chiropractic services in the Medicare program.  It consolidates 
the findings and issues identified in that work and discusses 
  recommendations from prior reports that have not been 
implemented or have been implemented ineffectively.  In 
addition, this portfolio provides information to help the Centers 
for Medicare & Medicaid Services understand the need for 
effective controls over chiropractic services and offers 
recommendations to help Medicare prevent fraud, waste, and 
abuse related to those services.    
 
The OIG work referenced throughout this portfolio was conducted in accordance with 
the Quality Standards for Inspection and Evaluation issued by the Council of the 
Inspectors General on Integrity and Efficiency, generally accepted government 
auditing standards, and investigative and legal professional standards, as applicable.   
Office of Inspector General 
https://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services (HHS) 
programs, as well as the health and welfare of beneficiaries served by those programs.  This 
statutory mission is carried out through a nation-wide network of audits, investigations, and 
inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting audits 
with its own audit resources or by overseeing audit work done by others.  Audits examine the 
performance of HHS programs and/or its grantees and contractors in carrying out their respective 
responsibilities and are intended to provide independent assessments of HHS programs and 
operations.  These assessments help reduce waste, abuse, and mismanagement and promote 
economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, 
Congress, and the public with timely, useful, and reliable information on significant issues.  These 
evaluations focus on preventing fraud, waste, or abuse and promoting economy, efficiency, and 
effectiveness of departmental programs.  To promote impact, OEI reports also present practical 
recommendations for improving program operations. 
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and 
misconduct related to HHS programs, operations, and beneficiaries.  With investigators working in all 
50 States and the District of Columbia, OI utilizes its resources by actively coordinating with the 
Department of Justice and other Federal, State, and local law enforcement authorities.  The 
investigative efforts of OI often lead to criminal convictions, administrative sanctions, and/or civil 
monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, 
rendering advice and opinions on HHS programs and operations and providing all legal support for 
OIGs internal operations.  OCIG represents OIG in all civil and administrative fraud and abuse cases 
involving HHS programs, including False Claims Act, program exclusion, and civil monetary penalty 
cases.  In connection with these cases, OCIG also negotiates and monitors corporate integrity 
agreements.  OCIG renders advisory opinions, issues compliance program guidance, publishes fraud 
alerts, and provides other guidance to the health care industry concerning the anti-kickback statute 
and other OIG enforcement authorities. 
 
 
 
 
       
                             
                                  
PORTFOLIO IN BRIEF 
 
 
 
Why a Portfolio? 
 
  The Centers for Medicare & Medicaid Services (CMS's) Comprehensive Error Rate Testing program, 
which measures improper Medicare fee-for-service payments annually, identified chiropractic services 
 
as having the highest improper payment rates among Medicare Part B services from 2010 to 2015.  
 
The improper payment rate for chiropractic services ranged from 43.9 percent to 54.1 percent, and the 
  estimated overpayments per year ranged from $257 million to $304 million.  Further, since 2005, the 
  Office of Inspector General (OIG) has conducted numerous evaluations and audits of chiropractic 
  services and identified hundreds of millions of dollars in overpayments.  Despite these findings, CMS 
has not implemented or effectively implemented all of our recommendations, and controls over 
 
chiropractic services remain inadequate to prevent fraud, waste, and abuse.  This overview of 
 
Medicare program vulnerabilities identified in prior OIG audits, evaluations, investigations, and legal 
actions related to chiropractic services illustrates the  need for better controls over those services to 
  protect the Medicare Trust Funds, help reduce the risk of fraud, and prevent beneficiaries from paying 
  millions of dollars in coinsurance for chiropractic services that are not reasonable or necessary.  
Further, chiropractic services that are not reasonabl e or necessary can potentially harm Medicare 
beneficiaries.    
 
 
 
 
    
What Action Is Needed? 
To help Medicare reduce fraud, waste, and abuse related to chiropractic services and ensure that 
chiropractors provide medically necessary services to protect the health and safety of Medicare 
beneficiaries, we recommend that CMS implement our prior recommendations that remain 
unimplemented or have been implemented ineffectively.  In addition, to further strengthen program 
integrity and facilitate the full implementation of our prior recommendations, CMS should (1) work with 
its contractors to educate chiropractors on the training materials that are available to them; 
(2) educate beneficiaries on the types of chiropractic services that are covered by Medicare, inform 
them that massage and acupuncture services are not covered by Medicare, and encourage them to 
report to CMS chiropractors who are providing non-Medicare-covered services; (3) identify 
chiropractors with aberrant billing patterns or high service-denial rates, select a statistically valid 
random sample of services provided by each chiropractor identified, review the medical records for the 
sampled services, estimate the amount overpaid to each chiropractor, and request that the 
chiropractors refund the amounts overpaid by Medicare; and (4) establish a threshold for the number 
of chiropractic services beyond which medical review would be required for additional services.  
CMSs comments on these recommendations and our responses are included in this portfolio. 
Chiropractic Services Portfolio (A-09-16-02042)     
TABLE OF CONTENTS 
 
   
BACKGROUND ............................................................................................................................................ 1 
 
Chiropractic Services ....................................................................................................................... 1 
 
Medicare Coverage of Chiropractic Services .................................................................................. 1 
 
Recent Statutory Changes for Oversight of Chiropractic Services .................................................. 2 
 
Historical Medicare Payments for Chiropractic Services ................................................................. 2 
 
Medicare Improper Payment Rates for Chiropractic Services ......................................................... 2 
 
ISSUES ......................................................................................................................................................... 4 
 
Medicare Continued To Make Hundreds of Millions in Improper Payments 
   for Chiropractic Services ............................................................................................................... 4 
 
CMSs Controls Have Not Fully Prevented Improper Payments ..................................................... 6 
The Requirement To Include the AT Modifier on Claims Has Not Fully 
   Prevented Payments for Maintenance Therapy .............................................................. 6 
The Requirement To Include the Initial Treatment Date on Claims Has Not  
   Ensured That Services Are Adequately Supported ......................................................... 7 
Provider Education Has Not Fully Prevented Improper Payments to Chiropractors .......... 7 
Reviewing Medical Records To Determine Whether Chiropractic Services 
   Met Medicare Requirements Has Not Been a High Priority for Contractors.................... 8 
   
Chiropractic Fraud Is a Concern ...................................................................................................... 9 
 
Establishing a Medical Review Threshold for Chiropractic Services Could Save Millions by 
   Reducing Payments for Medically Unnecessary Services Without Compromising  
   Beneficiary Access to Reasonable and Necessary Services ..................................................... 10 
CMS Guidance on Limits for Chiropractic Services .......................................................... 10 
Private Insurances Limits on Chiropractic Services ......................................................... 11 
The Greater the Number of Chiropractic Services Received by a Beneficiary, 
   the More Likely That the Services Are Medically Unnecessary ..................................... 11 
Medicare and Its Beneficiaries Could Achieve Cost Savings if Medicare  
   Established a Medical Review Threshold for Chiropractic Services .............................. 12 
 
RECOMMENDATIONS FROM PRIOR OFFICE OF INSPECTOR GENERAL REPORTS 
   THAT REMAIN UNIMPLEMENTED OR HAVE BEEN IMPLEMENTED INEFFECTIVELY .................... 14 
 
Unimplemented Recommendations ............................................................................................... 14 
 
Ineffectively Implemented Recommendations ............................................................................... 15 
   
CONCLUSION ............................................................................................................................................ 16 
 
RECOMMENDATIONS ............................................................................................................................... 17 
 
CMS COMMENTS AND OFFICE OF INSPECTOR GENERAL RESPONSE ............................................ 18 
CMS Comments ............................................................................................................................. 18 
Chiropractic Services Portfolio (A-09-16-02042)     
Office of Inspector General Response ........................................................................................... 19 
APPENDIX A: PRIOR OFFICE OF INSPECTOR GENERAL REPORTS .................................................. 20 
APPENDIX B: CMS COMMENTS .............................................................................................................. 21 
ENDNOTES ................................................................................................................................................ 24 
Chiropractic Services Portfolio (A-09-16-02042)     
BACKGROUND 
 
 
Chiropractic Services 
What does Medicare   
Chiropractic is a form of alternative medicine.  Chiropractic services 
Part B cover? 
focus on the diagnosis and treatment of disorders of the 
Medicare Part B covers medical 
musculoskeletal system, especially the spine.  The most common 
and other health care services, 
therapeutic procedure that chiropractors perform is spinal 
including chiropractic services. 
  manipulation.  The purpose of this procedure is to restore joint 
How much does  mobility by manually applying a controlled force into joints that have 
Medicare pay yearly for  become restricted in their movement as a result of an injury to the 
chiropractic services?  tissue.   
 
Since 2010, Medicare has paid 
more than $450 million per year  Medicare Coverage of Chiropractic Services 
for chiropractic services.   
  Medicare covers chiropractic services for active/corrective 
What are the coverage  treatment for subluxation of the spine (when spinal bones are 
rules for chiropractic  misaligned) by means of manual manipulation of the spine.1  
services?  Medicare does not cover chiropractic maintenance therapy, 
however, because it prohibits payment for items or services that are 
Medicare covers reasonable and 
necessary chiropractic services  not reasonable and necessary for the diagnosis or treatment of 
provided by a qualified  illness or injury or to improve the functioning of a malformed body 
chiropractor to correct spinal  member.2  Maintenance therapy includes services that seek to 
subluxation by means of manual 
prevent disease, promote health, and prolong and enhance the 
manipulation of the spine.  
quality of life or to maintain or prevent deterioration of a chronic 
Medicare does not cover 
chiropractic maintenance  condition.  The Centers for Medicare & Medicaid Services (CMS) 
therapy.  To receive payment  guidance states: When further clinical improvement cannot 
from Medicare, a chiropractor  reasonably be expected from continuous ongoing care, and the 
must have documentation to 
chiropractic treatment becomes supportive rather than corrective in 
support the services provided. 
nature, the treatment is then considered maintenance therapy.3 
 
 
Is there a limit to the 
Medicare requires chiropractors to place the Acute Treatment (AT) 
number of covered 
modifier on a claim when providing active/corrective treatment for 
chiropractic services 
subluxation.4  Because Medicare considers claims without the AT 
that a beneficiary may 
modifier to be claims for services that are maintenance therapy, it 
receive? 
denies these claims.  However, inclusion of the AT modifier does 
Medicare does not limit the 
not always indicate that the service provided was reasonable and 
number of covered chiropractic 
necessary.5   
services that a beneficiary may 
receive per month or per year.    
Many private insurance  In addition, Medicare requires chiropractors to enter the date of the 
companies impose coverage  initial treatment on a claim.  By entering the date, the chiropractor 
limits.   
affirms that all documentation required by Medicare is being 
maintained on file.6   
 
 
Chiropractic Services Portfolio (A-09-16-02042)  1   
CMS contracts with Medicare administrative contractors (contractors) to process and pay 
Medicare Part B claims, which include claims for chiropractic services.  The contractors use 
system edits to determine whether these claims are complete and payable.7  Each contractor 
makes coverage decisions for services provided in its jurisdiction.   
 
Recent Statutory Changes for Oversight of Chiropractic Services 
 
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) contains provisions for 
oversight of chiropractic services.8  The MACRA requires that the Secretary of Health and 
Human Services implement a prior-authorization process for certain chiropractic services 
provided on or after January 1, 2017.  Specifically, those services must be part of a course of 
treatment that includes more than 12 services, focusing on services such as those provided by 
chiropractors with aberrant billing patterns9 and by chiropractors who, in a prior period, had a 
service-denial percentage in the 85th percentile or greater.10  The law also requires that the 
Secretary develop and make publicly available by January 1, 2016, educational and training 
programs to improve a chiropractors ability to provide documentation demonstrating that 
services are reasonable and necessary.11   
 
Historical Medicare Payments for Chiropractic Services 
 
From calendar years (CYs) 2010 through 2015, Medicare consistently paid more than 
$450 million per year for chiropractic services (Figure 1).  In this 6-year span, Medicare paid a 
total of $2.9 billion for chiropractic services.   
 
Figure 1: Paid Amounts for Chiropractic Services, CYs 20102015 
 
 
 
Medicare Improper Payment Rates for Chiropractic Services 
 
CMSs Comprehensive Error Rate Testing (CERT) program, which measures improper 
Medicare fee-for-service payments annually, identified chiropractic services as having the 
highest improper payment rates among Medicare Part B services from fiscal years 2010 through 
Chiropractic Services Portfolio (A-09-16-02042)  2   
2015 (which includes claims from April 1, 2009, through June 30, 2014).  During this period, the 
improper payment rate for chiropractic services ranged from 43.9 percent to 54.1 percent 
compared with 9.9 percent to 12.9 percent for all Part B services (Figure 2), and the estimated 
overpayments for chiropractic services ranged from $257 million to $304 million.12  The CERT 
program identified that improper payments were made for services that were medically 
unnecessary, billed with an incorrect procedure code, not documented, or insufficiently 
documented. 
 
Figure 2: Comparison of Improper Payment Rates for Chiropractic Services  
and All Medicare Part B Services  
 
 
 
The contractors told us that they have also reviewed claims for chiropractic services and found 
similar issues.  According to the contractors we interviewed, claims for chiropractic services 
were typically denied because the services were medically unnecessary, billed with an incorrect 
procedure code, not documented, or insufficiently documented. 
   
Chiropractic Services Portfolio (A-09-16-02042)  3   
ISSUES 
 
 
Our evaluation and audit reports have identified hundreds of millions in overpayments for 
chiropractic services that did not meet Medicare requirements.  Our investigations and legal 
actions involving chiropractors have demonstrated that chiropractic services are also susceptible 
to health care fraud.   
 
By analyzing our prior work on chiropractic services, we identified the following issues: 
 
  Medicare continued to make hundreds of millions in improper payments for chiropractic 
services. 
 
  CMSs controls have not fully prevented improper payments. 
 
  Chiropractic fraud is a concern. 
 
  Establishing a medical review threshold for chiropractic services could save millions by 
reducing payments for medically unnecessary services without compromising beneficiary 
access to reasonable and necessary services. 
 
Medicare Continued To Make Hundreds of Millions in Improper Payments for 
Chiropractic Services 
 
The results of our work and that of the CERT program showed that since CY 2001 Medicare 
continued to make hundreds of millions in improper payments for chiropractic services.  The 
majority of the improper payments that we identified were for services that Medicare considers 
medically unnecessary, including maintenance therapy, which is not covered by Medicare.  
Further, Medicare beneficiaries continued to pay millions of dollars in coinsurance for 
unallowable chiropractic services.13  Figure 3 on the following page provides key findings from 
our prior reviews of chiropractic services.  (Appendix A contains a list of the reports.) 
   
Chiropractic Services Portfolio (A-09-16-02042)  4   
Figure 3: Prior Office of Inspector General (OIG) Reviews of Chiropractic Services 
  This review found that Medicare made $285 million in improper 
payments for chiropractic services that were medically 
unnecessary, billed with the incorrect procedure code, or 
undocumented.  Seventy-four percent of the medically unnecessary 
services were for maintenance therapy.14  
   
This review focused on chiropractic services provided to beneficiaries 
who had received more than 12 services from the same chiropractor 
and found that Medicare made $178 million in improper payments 
for services that were maintenance therapy, billed with the 
incorrect procedure code, or undocumented.  Of this amount, 
$157 million (88 percent) was for maintenance therapy services.15   
   
These five reviews of individual chiropractors identified improper 
payment rates ranging from 77 percent to 97 percent and estimated 
overpayments of $2.9 million for services that were medically 
unnecessary, billed with the incorrect procedure code, not 
documented, or insufficiently documented.16 
  This review of questionable billing found that Medicare paid 
$76 million for chiropractic services that were questionable.  Of 
this amount, $34 million (45 percent) was paid for chiropractic 
services that appeared to be for maintenance therapy.  This review also 
found questionable payments related to issues such as chiropractors 
incorrectly coding claims to receive a higher payment and providing 
an unlikely number of services per day.17   
  This nation-wide review of chiropractic services identified an 
improper payment rate of 82 percent and estimated 
overpayments of $358.8 million.  This review showed that 94 of the 
105 sampled chiropractic services (approximately 90 percent) were 
medically unnecessary.  Medicare beneficiaries paid $91 million in 
coinsurance for the medically unnecessary services.18  
   
Chiropractic Services Portfolio (A-09-16-02042)  5   
CMSs Controls Have Not Fully Prevented Improper Payments  
 
Our work shows that CMSs controls have not fully prevented improper payments for 
chiropractic services: 
 
  The requirement to include the AT modifier on claims 
What Is CMSs Role in 
has not fully prevented payments for maintenance 
Medicare Oversight? 
therapy, which are unallowable. 
One of CMSs key responsibilities is to 
 
protect Medicare from fraud, waste, 
  The requirement to include the initial treatment date 
and abuse.  To ensure the integrity of 
on claims has not ensured that services are adequately  Medicare, CMS issues program 
supported.  manuals and guidance and 
  implements controls to prevent 
improper payments.  Some of these 
  Provider education has not fully prevented improper 
controls are implemented by the 
payments to chiropractors. 
contractors. 
 
  Reviewing medical records to determine whether chiropractic services met Medicare 
requirements has not been a high priority for contractors. 
 
The Requirement To Include the AT Modifier on Claims Has Not Fully Prevented 
Payments for Maintenance Therapy  
 
In response to our CY 2001 review, CMS stated that it had implemented the use of the AT 
modifier for chiropractic services to help chiropractors bill correctly.  Effective October 1, 2004, 
Medicare required chiropractors to place the AT modifier on a claim when providing 
active/corrective treatment for subluxation.19  Because Medicare considers claims without the 
AT modifier to be claims for services that are maintenance therapy, it denies these claims.  
However, the requirement to include the AT modifier has not been effective in fully preventing 
payments for maintenance therapy.   
 
Our work showed that almost all claims for chiropractic services 
What Did the  had the AT modifier regardless of whether the services were for 
CY 2015 Payment  active/corrective treatment for subluxation.  For example, our 
Data Show?  CY 2013 questionable billing review found that every claim that 
appeared to be for maintenance therapy included the AT modifier.  
Claims for all but 30 of the 
nearly 14 million  Further, all of the 105 sampled chiropractic services included in 
chiropractic services paid  our CY 2013 nation-wide review were on claims that had the AT 
by Medicare had the AT 
modifier, and 94 of those services, or 90 percent, were medically 
modifier. 
unnecessary, which included services for maintenance therapy.   
 
The medical reviewers and contractor staff whom we interviewed for the CY 2006 review agreed 
that the AT modifier did not prevent inappropriate payments for maintenance therapy.  A staff 
member from one contractor stated: By putting an AT modifier on a claim, chiropractors are 
getting paid, and they know they will get paid.  In addition, the medical reviewers for the 
CY 2006 review noted that the requirement to include the AT modifier did not appear to affect 
chiropractic billing patterns.  Finally, a biller, who had worked for one of the five individual 
Chiropractic Services Portfolio (A-09-16-02042)  6   
chiropractors whom we audited for the CYs 2010 through 2013 reviews, informed us that the 
computerized program used to bill Medicare for chiropractic services automatically included the 
AT modifier on the claim form. 
 
The Requirement To Include the Initial Treatment Date on Claims Has Not Ensured That 
Services Are Adequately Supported 
 
Medicare requires chiropractors to enter on a claim the date of the initial treatment, which serves 
as the chiropractors affirmation that all required documentation is being maintained on file.  
Seven of the eight contractors informed us that there was a system edit to ensure that the initial 
treatment date was included on claims and that claims without that date would be denied.  
However, the requirement to include the initial treatment date on claims has not been effective in 
ensuring that chiropractic services are adequately supported.   
 
Our analysis of the claim data for the 652 sampled services that we reviewed as part of the 
CY 2013 nation-wide review and five reviews of individual chiropractors for CYs 2010 through 
2013 showed that chiropractors submitted all of the claims with the initial treatment date, 
affirming that the required documentation was being maintained on file.  However, the 
chiropractors did not document the medical necessity of 559 services (86 percent) as required by 
Medicare; an additional 56 services (9 percent) were either not documented or insufficiently 
documented.  These results are consistent with our CY 2001 review, which found that 94 percent 
of chiropractic services reviewed lacked some or all of the supporting documentation that CMSs 
Medicare Benefit Policy Manual requires.  The results of our analysis indicate that chiropractors 
included the initial treatment date on claims to ensure that the claims would get paid regardless 
of whether the services were adequately documented.   
 
Provider Education Has Not Fully Prevented 
Does CMS Provide Education to 
Improper Payments to Chiropractors  
Beneficiaries on Chiropractic Services? 
 
CMS and the contractors published on their  CMS publishes educational materials on its website 
Medicare.gov: Medicare & You and Your Medicare 
websites Medicare policies and educational 
Benefits.  These publications explain that the 
materials to provide information on Medicare 
Medicare benefit for chiropractic services is limited to 
requirements for chiropractic services.  However, 
manipulation of the spine if it is medically necessary 
providing these materials has not been effective in  to correct a subluxation.  Neither publication mentions 
fully preventing improper payments to  maintenance therapy nor indicates that maintenance 
chiropractors.  The high improper payment rates  therapy is not covered by Medicare.    
 
in both the CERT and OIG reviews suggest that 
CMS sends Medicare & You to beneficiaries 
many chiropractors did not use these materials to 
annually; however, beneficiaries whom we 
get a better understanding of how to properly bill  interviewed did not know that the services they 
for chiropractic services.  One contractor stated  received from chiropractors would not be covered by 
that many chiropractors did not know the  Medicare.  One beneficiary with degenerative disc 
disease told us that the oil-based massages and 
Medicare requirements outlined in the Local 
electric stimulation treatment he got during his visits 
Coverage Determinations and that the 
to the chiropractor did not help his symptoms.  
chiropractors in its jurisdiction were resistant to  Another beneficiary with arthritis said that the 
education and not willing to change their billing  massages she received at the chiropractors office 
patterns.20    helped her relax.   
 
Chiropractic Services Portfolio (A-09-16-02042)  7   
The MACRA required educational and training programs for chiropractors, both to improve their 
ability to document services and to increase their compliance with Medicare policies.  To address 
this requirement, on December 23, 2015, CMS made available a training video entitled 
Improving the Documentation of Chiropractic Services on the CMS YouTube channel.  CMS 
stated that this video would help to reduce the improper payment rate by helping chiropractors to 
properly document services provided.  However, many chiropractors have not accessed this 
training.  As of January 2, 2017, the video had been viewed only 8,898 times.  In CY 2016, 
41,012 chiropractors submitted claims to Medicare for chiropractic services.  CMS could work 
with its contractors to educate chiropractors on the training materials that are available to them.   
 
Reviewing Medical Records To Determine Whether Chiropractic Services Met Medicare 
Requirements Has Not Been a High Priority for Contractors  
 
Most Medicare claims are processed and paid without a review  What Is Medical Review? 
of the underlying medical records to support the claim.  
Medical review is the collection of 
Medicare can use medical review, including prepayment or  information and review of medical 
postpayment reviews, to determine whether a claimed service  records to ensure that payment is 
made only for services that meet 
was reasonable and necessary or otherwise satisfied Medicare 
all Medicare coverage, coding, 
coverage and payment requirements.  Medical review is an 
and medical necessity 
effective tool for identifying services that do not meet 
requirements. 
Medicare requirements and educating chiropractors on those 
requirements.  However, the contractors have not widely used 
medical reviews because, according to CMS, the contractors have targeted their efforts on 
services that pose the greatest financial risk to the Medicare program, and they have limited 
resources.  In addition, improper payments for chiropractic services have accounted for less than 
1 percent of the total improper payments in Medicare fee-for-service.  Finally, chiropractic 
services have relatively small payments when compared with other Medicare-covered services.  
The payments for a chiropractic service ranged from $29 to $54 in CY 2016. 
 
Although Medicare payments for chiropractic services are relatively small, since CY 2010 
Medicare has paid more than $450 million per year for these services.  In addition, our CY 2013 
nation-wide review, which used a medical review contractor to determine the medical necessity 
of services, found that Medicare paid almost $359 million for chiropractic services that were not 
allowable in accordance with Medicare requirements.  This demonstrates that medical review is 
effective in detecting improper payments for chiropractic services.  However, CMS and its 
contractors have not prioritized conducting medical review on chiropractic services because the 
Medicare payment per service is relatively low when compared with other services.  For a 
chiropractor with questionable billing practices or high service-denial rates, the contractor could 
review a statistically valid sample of claims submitted by the chiropractor for the year and 
estimate the amount overpaid for the year.   
   
Chiropractic Services Portfolio (A-09-16-02042)  8   
Chiropractic Fraud Is a Concern 
 
We have completed investigations of 28 chiropractic fraud cases since 2005.  To defraud the 
Federal Government, chiropractors: 
 
Investigation Found Chiropractor 
  submitted claims for services that were 
Committed Fraud, Leading to Prison 
never provided, 
Time and Restitution 
 
  submitted claims for medically  We contacted a chiropractor to obtain medical 
unnecessary services,   records for an audit.  Before the scheduled 
review, the chiropractor falsely reported to the 
 
police that he had been robbed and that the 
  offered incentives to patients to receive 
patient files that we had requested had been 
unnecessary services,  stolen from his car.  These events led to a fraud 
  investigation against this chiropractor. 
 
  provided services without a valid 
When we interviewed the chiropractors 
chiropractic license,  
patients, most of them described the treatment 
  they received as a massage, which is not a 
  falsified patient records, and   Medicare-covered service.  For example, a 
  beneficiary told us that a driver employed by the 
chiropractor provided a massage that did not 
  billed for chiropractic services but 
help the beneficiarys condition.  Another 
provided services not covered by 
beneficiary described the services she received 
Medicare (e.g., massage and  as soft massages and said that she stopped 
acupuncture).  seeing the chiropractor because her symptoms 
did not improve.   
 
 
These investigations resulted in incarceration for 
The chiropractor pleaded guilty to health care 
11 chiropractors and approximately $7.6 million 
fraud and filing a false police report.  He was 
in restitution and settlements.  Some of the  sentenced to 63 months in Federal prison and 
investigations that did not result in incarceration  ordered to pay full restitution of more than 
$1 million.  He was also excluded from 
resulted in the chiropractors being excluded from 
participating in Medicare for 23 years. 
participating in Medicare.21   
 
In addition to these investigations, we have imposed program exclusions and civil monetary 
penalties on chiropractors for submitting false or fraudulent claims.  For example, on 
December 16, 2016, we excluded a chiropractor from participating in Medicare for 40 years for 
submitting claims for chiropractic services that were not medically necessary and not provided as 
claimed.  From CYs 2005 through 2016, we excluded 542 chiropractors from Medicare for 
various periods.22   
 
Fraudulent chiropractic services can potentially cost Medicare millions of dollars and 
compromise the health and safety of Medicare beneficiaries.  For example, beneficiaries may be 
injured by receiving chiropractic services that are medically unnecessary or provided by an 
individual without a valid chiropractic license.   
 
 
 
Chiropractic Services Portfolio (A-09-16-02042)  9   
Establishing a Medical Review Threshold for Chiropractic Services Could Save 
Millions by Reducing Payments for Medically Unnecessary Services Without 
Compromising Beneficiary Access to Reasonable and Necessary Services 
 
Medicare does not cover chiropractic maintenance therapy because Medicare prohibits payment 
for items or services that are not reasonable and necessary for the diagnosis or treatment of 
illness or injury or to improve the functioning of a malformed body member.  CMS guidance 
states: When further clinical improvement cannot reasonably be expected from continuous 
ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, 
the treatment is then considered maintenance therapy.23   
 
The majority of the improper payments that we identified in our prior reviews were for services 
that Medicare considers medically unnecessary, including maintenance therapy.  Our work 
shows that Medicare could save millions of dollars by establishing a threshold beyond which 
chiropractic services would be covered only if supported by medical review.  For example, CMS 
could set a threshold for the number of chiropractic services that a beneficiary may receive per 
year and require medical review for services in excess of that threshold.  This approach could 
save Medicare millions of dollars without compromising beneficiary access to reasonable and 
necessary services in excess of that threshold.   
 
Does Medicare Have Medical Review Thresholds for Other Types of Services? 
Medicare has a medical review threshold for outpatient therapy services (as authorized by the Social 
Security Act  1833(g)).  For example, the threshold for payments per beneficiary per year for 
outpatient physical therapy and speech-language pathology services combined was $1,920 for 
CY 2014.  There are exceptions for exceeding the threshold for therapy services that are reasonable 
and necessary, but combined services above $3,700 are subject to medical review. 
 
CMS Guidance on Limits for Chiropractic 
Do Medicare Contractors Have 
Services 
Guidance on Medical Review 
 
Thresholds? 
The Medicare Benefit Policy Manual and the 
Medicare Claims Processing Manual do not include  Since 2012, two of the Medicare 
information on limits for chiropractic services.   contractors set medical review 
thresholds for chiropractic services 
According to CMSs Medicare Learning Network 
within their jurisdictions.  One 
factsheet Misinformation on Chiropractic Services, 
contractors threshold was 12 services 
Medicare does not limit the number of services that  per beneficiary per month but not more 
beneficiaries may receive for covered chiropractic  than 30 per year, and the other 
care.24  The factsheet states that contractors may  contractors threshold was 25 services 
per beneficiary per year.  Services in 
specify a number of services for which a review of 
excess of these thresholds may be paid 
documentation may be required, but limits are not 
if the chiropractor submits additional 
allowed.    documentation to support the medical 
  necessity of the services. 
 
 
 
Chiropractic Services Portfolio (A-09-16-02042)  10   
Private Insurances Limits on Chiropractic Services 
 
Similar to Medicare, some private insurance companies provide coverage for chiropractic 
services.  For example, many of the private insurance companies that participate in the Federal 
Employees Health Benefits (FEHB) program provide coverage for chiropractic services, and 
most of them limit the number of chiropractic services they will pay for.  However, Medicare 
must cover reasonable and necessary services and follow certain statutory rules that do not apply 
to private insurance companies, including those that participate in the FEHB program.   
 
To understand the coverage limits imposed by private insurance companies and how medical 
review thresholds similar to these limits might result in cost savings for Medicare, we analyzed 
the private insurance plans offered to Federal employees by the FEHB program in CY 2014 and 
found that 61 percent of the plans limited the number of chiropractic services covered per 
beneficiary per year.  The maximum number of chiropractic services that these plans covered 
averaged 21 per year and ranged from 10 to 60 per year.  The most common limit was 
20 services per year.  The FEHB brochures for the plans with limits did not indicate whether 
these plans would allow additional services on the basis of medical necessity.  Some plan 
brochures specifically stated that the insured is responsible for paying for services in excess of 
the limit.  
 
The remaining 39 percent of the FEHB plans did not provide any coverage for chiropractic 
services or covered an unlimited number of them per year.  Many plans that covered an 
unlimited number of services required prior authorization or required the enrollee to pay 
significant out-of-pocket costs.  
 
The Greater the Number of Chiropractic Services Received by a Beneficiary,  
the More Likely That the Services Are Medically Unnecessary 
 
The results of our CY 2001 review and CY 2013 nation-wide review demonstrate that the greater 
the number of chiropractic services received by a beneficiary during the year, the more likely 
that the services are medically unnecessary.  Figure 4 on the following page shows the results of 
our CY 2013 nation-wide review. 
   
Chiropractic Services Portfolio (A-09-16-02042)  11   
Figure 4: Results of CY 2013 Nation-wide Review 
 
 
 
None of the services in group 3 (the 31st and subsequent services) were medically necessary.  
Also, none of these services were processed by either of the 2 contractors that established 
medical review thresholds of 25 and 30 services per beneficiary per year, respectively.   
 
Medicare and Its Beneficiaries Could Achieve Cost Savings if Medicare Established a 
Medical Review Threshold for Chiropractic Services 
 
Table 1 shows the amounts that Medicare could have potentially saved in CYs 2013 through 
2015 if there had been a threshold of 12 and 30 chiropractic services per beneficiary per year, 
respectively, and medical review had been required for services in excess of those thresholds. 
 
Table 1: Potential Cost Savings to Medicare in CYs 20132015 
With Medical Review Thresholds for Chiropractic Services 
 
Medical Review         
Threshold for        Total Potential 
Chiropractic  Potential Savings  Potential Savings  Potential Savings  Savings in 
Services  in CY 2013  in CY 2014  in CY 2015  CYs 20132015 
12  $135,615,180  $157,960,368  $153,267,127  $446,842,675 
30  $28,697,760  $33,629,675  $32,778,844  $95,106,279 
 
Chiropractic Services Portfolio (A-09-16-02042)  12   
Establishing a medical review threshold for chiropractic services could also potentially save 
beneficiaries millions in coinsurance payments for medically unnecessary services.  Table 2 
shows the amounts that Medicare beneficiaries could have potentially saved in CYs 2013 
through 2015 if there had been a threshold of 12 and 30 chiropractic services per beneficiary per 
year, respectively, and medical review had been required for services in excess of those 
thresholds. 
 
Table 2: Potential Cost Savings to Medicare Beneficiaries in CYs 20132015 
With Medical Review Thresholds for Chiropractic Services 
 
Medical Review         
Threshold for        Total Potential 
Chiropractic  Potential Savings  Potential Savings  Potential Savings  Savings in 
Services  in CY 2013  in CY 2014  in CY 2015  CYs 20132015 
12  $34,545,604  $40,278,962  $39,084,796  $113,909,362 
30  $7,319,043  $8,577,961  $8,361,033  $24,258,037 
 
   
Chiropractic Services Portfolio (A-09-16-02042)  13   
 
RECOMMENDATIONS FROM PRIOR 
OFFICE OF INSPECTOR GENERAL REPORTS THAT REMAIN 
UNIMPLEMENTED OR HAVE BEEN IMPLEMENTED INEFFECTIVELY  
 
 
A key component of effective oversight of chiropractic services is monitoring chiropractor 
billing and establishing methods to prevent and detect fraud, waste, and abuse.  In prior reports, 
OIG made numerous recommendations to address vulnerabilities, and in some instances CMS 
took action to implement our recommendations and strengthen controls over billing for 
chiropractic services.  However, Medicare continues to make hundreds of millions in improper 
payments for chiropractic services. 
 
As the agency charged with administering and overseeing chiropractic services, CMS is 
responsible for improving the effectiveness of controls over chiropractic services and protecting 
Medicare beneficiaries.  We are highlighting the following recommendations made to CMS in 
previous OIG reports that remain unimplemented or have been implemented ineffectively.  We 
encourage CMS to continue taking actions to implement our recommendations and strengthen 
controls over billing for chiropractic services.   
 
Unimplemented Recommendations 
 
Recommendation: Implement and enforce policies to prevent future 
payments for maintenance therapy (e.g., by implementing a new 
CY 2006  modifier for chiropractic claims to indicate the start of a new 
Review  treatment episode so that contractors can identify aberrant treatment 
patterns through claims data).25 
   
CMS did not indicate whether it concurred with this recommendation 
but stated that it would consider implementing a modifier to indicate the start of a new treatment 
episode if it were feasible.  As of January 2017, CMS had not implemented such a modifier.   
 
Recommendation: Establish a more reliable control for 
CY 2013  identifying active treatment.26   
Questionable   
Billing  CMS did not concur with this recommendation, citing significant 
obstacles to establishing a more reliable control for identifying 
Review 
  active treatment.  CMS stated that it would implement a medical 
review process for preauthorizing certain chiropractic services as 
required by the MACRA, which it believed would help address the concerns we identified.  
Because the MACRA provision focuses on chiropractors with aberrant billing patterns and high 
service-denial rates, it would not be effective in preventing improper payments made to other 
chiropractors who bill for medically unnecessary chiropractic services.  In addition, our CY 2013 
nation-wide review demonstrated that improper payments were not limited to chiropractors with 
Chiropractic Services Portfolio (A-09-16-02042)  14   
aberrant billing patterns or high service-denial rates and were a widespread issue for all 
chiropractors.   
 
Recommendation: Determine a reasonable number of chiropractic 
services that are necessary to actively treat spinal subluxation and 
CY 2013 
implement an edit to identify for review services in excess of that 
Nation -wide  number.27 
Review 
 
CMS concurred with this recommendation and stated that it would 
monitor the results of its effort to implement medical review for 
preauthorizing certain chiropractic services as required by the MACRA and would determine 
whether further action was warranted.  However, CMSs proposed action would not adequately 
address our concerns because, as previously stated, this MACRA provision focuses on 
chiropractors with aberrant billing patterns and high service-denial rates.   
 
Recommendation: Determine whether there should be a limit for 
the number of chiropractic services that Medicare will reimburse; if 
CY 2013  so, take appropriate action to put that limit into effect, and 
Nation-wide  implement an edit to disallow services in excess of that limit.28   
Review   
CMS did not concur with this recommendation.  In our report related 
 
to our CY 2006 review, we made a similar recommendation that 
CMS implement a cap on the number of chiropractic services that a beneficiary may receive per 
year.  CMS did not indicate then whether it concurred with that recommendation and commented 
that the objective data required to implement a national cap did not exist.   
 
To provide CMS additional data, we conducted our CY 2013 nation-wide review, which found 
an 82 percent improper payment rate, resulting in $358.8 million in overpayments.  In addition, 
this review showed that as the number of chiropractic services received by a beneficiary 
increased, the improper payment rate also increased.  Specifically, services in excess of 30 per 
beneficiary per year were all unallowable.  When we recommended in our draft report that CMS 
address these issues with, among other recommendations, a limit to services, it stated that to 
implement our recommendation it would need to develop a National Coverage Determination 
(NCD) and was unaware of medical evidence to support such an NCD.29  In response to CMSs 
comments, we refined our final report for the CY 2013 nation-wide review to include the 
recommendation above.  We suggested that if CMS was unable to obtain the evidence needed to 
support an NCD, CMS should consider taking other appropriate actions.   
 
Ineffectively Implemented Recommendations 
 
Recommendation: Ensure that chiropractic services comply with 
Medicare coverage criteria.30 
CY 2001 
 
Review 
CMS concurred with this recommendation and stated that it had 
implemented the use of the AT modifier for chiropractic services to 
 
help chiropractors bill correctly.  However, our work shows that the 
Chiropractic Services Portfolio (A-09-16-02042)  15   
AT modifier has not been fully effective in ensuring that chiropractic services comply with 
Medicare coverage criteria.  Specifically, it has not been fully effective in preventing payments 
for maintenance therapy, which are unallowable for Medicare reimbursement.  It is apparent that 
many chiropractors use the AT modifier to ensure that their claims get paid regardless of whether 
the services were for active/corrective treatment for subluxation.   
 
Recommendation: Improve education of chiropractors on 
Medicare coverage requirements for chiropractic services and the 
CY 2013  proper use of the AT modifier to ensure that only medically 
Nation-wide  necessary chiropractic services are billed to Medicare.31 
Review   
  CMS concurred with this recommendation and stated that since 
CY 2013 it has published several resources to educate providers on 
the coverage and billing requirements for chiropractic services, including proper use of the AT 
modifier.  CMS also stated that it has discussed chiropractic coverage and billing requirements 
through local education activities. 
 
Our work shows that despite CMSs efforts (e.g., provider education and the requirement to 
include the initial treatment date on claims), many chiropractors have continued to bill for 
services that are medically unnecessary or not adequately supported.  In addition, this portfolio 
shows that many chiropractors have not accessed CMSs resources.  From December 2015 to 
January 2017, a training video that CMS developed to help chiropractors properly document 
services had been viewed only 8,898 times.  This is a relatively low number compared with the 
41,012 chiropractors who submitted Medicare claims for chiropractic services in CY 2016.   
 
CONCLUSION 
 
 
Our evaluations and audits over a 13-year period from CYs 2001 through 2013 identified that 
Medicare paid hundreds of millions for chiropractic services that did not meet Medicare 
requirements, including the requirement that services be medically necessary.  We also identified 
vulnerabilities in the oversight of chiropractic services and made many recommendations to 
CMS to address those vulnerabilities.  In addition, our investigations and legal actions 
demonstrated that chiropractic services were susceptible to Medicare fraud.   
 
CMS has taken actions to address program vulnerabilities in chiropractic services, but these 
actions have not always been effective.  Our work demonstrates that CMSs controls (i.e., the 
requirements to include the AT modifier and initial treatment date on claims) have not fully 
prevented improper payments for chiropractic services.  In addition, provider education that 
CMS has provided has been ineffective in eliminating improper payments for chiropractic 
services.  Although medical review has been effective in reducing improper payments for various 
services in Medicare, it has not been commonly used for chiropractic services.   
 
CMS has implemented some of our recommendations, but others remain unimplemented.  For 
example, CMS has not taken actions to determine a reasonable number of chiropractic services 
that are necessary to actively treat spinal subluxation and identify for review services in excess 
Chiropractic Services Portfolio (A-09-16-02042)  16   
of that number, a control that has been used by two of CMSs contractors.  Medicare has also 
used such a control for outpatient physical therapy and speech-language pathology services.  Our 
work shows that if CMS established a threshold for the number of chiropractic services beyond 
which medical review would be required for additional services, Medicare could save millions of 
dollars by reducing payments for medically unnecessary services without compromising 
beneficiary access to reasonable and necessary services.  Specifically, if the threshold had been 
30 services per beneficiary per year and medical review had determined additional services to be 
unnecessary, Medicare could have potentially saved an estimated $95.1 million for CYs 2013 
through 2015, and Medicare beneficiaries could have potentially saved $24.3 million during that 
period by not having to pay coinsurance for medically unnecessary services. 
 
RECOMMENDATIONS 
 
 
To help Medicare reduce fraud, waste, and abuse related to chiropractic services and ensure that 
chiropractors provide medically necessary services to protect the health and safety of Medicare 
beneficiaries, we recommend that CMS implement the recommendations from prior OIG reports 
that were not implemented or were ineffectively implemented.  In addition, to further strengthen 
program integrity and facilitate the full implementation of our prior recommendations, CMS 
should: 
 
  work with its contractors to educate chiropractors on the training materials that are 
available to them;  
 
  educate beneficiaries on the types of chiropractic services that are covered by Medicare, 
inform them that massage and acupuncture services are not covered by Medicare, and 
encourage them to report to CMS chiropractors who are providing non-Medicare-covered 
services;  
 
  identify chiropractors with aberrant billing patterns or high service-denial rates, select a 
statistically valid random sample of services provided by each chiropractor identified, 
review the medical records for the sampled services, estimate the amount overpaid to 
each chiropractor, and request that the chiropractors refund the amounts overpaid by 
Medicare; and 
 
  establish a threshold for the number of chiropractic services beyond which medical 
review would be required for additional services. 
   
Chiropractic Services Portfolio (A-09-16-02042)  17   
CMS COMMENTS AND 
OFFICE OF INSPECTOR GENERAL RESPONSE 
 
 
In written comments on the new recommendations in our draft portfolio, CMS concurred with 
our first and second recommendations and provided information on actions that it had taken or 
planned to take to address those recommendations.  However, CMS did not concur with our third 
and fourth recommendations.  CMS also provided technical comments on our draft portfolio, 
which we addressed as appropriate.  CMSs comments, excluding the technical comments, are 
included as Appendix B. 
 
CMS Comments 
 
Before addressing our specific recommendations, CMS provided information on its Fraud 
Prevention System to identify aberrant and suspicious billing patterns and commented that 
several chiropractic models within that system analyze claims to detect potential fraud, waste, 
and abuse.  CMS also commented that, although it shares our concern regarding the improper 
payment rate for chiropractic services, the improper payments for these services account for less 
than 1 percent of the total improper payments for Medicare fee-for-service.  CMS stated that it is 
committed to using its resources to most efficiently address fraud, waste, and abuse and 
considers multiple factors, including potential savings, when targeting program integrity 
resources for specific services. 
 
CMSs comments on our new recommendations were as follows: 
 
  Regarding our first recommendation, CMS stated that it would continue to work with its 
contractors to promote education and training materials to chiropractors. 
 
  Regarding our second recommendation, CMS stated that it provides information on 
Medicare.gov and in written materials, such as the Medicare & You handbook and the 
Your Medicare Benefits booklet, to educate beneficiaries on covered and noncovered 
Medicare services, including chiropractic services.  In addition, CMS stated that it had 
recently updated Medicare.gov to highlight that acupuncture is not a covered chiropractic 
service and to encourage beneficiaries to report suspected fraud by chiropractors.  CMS 
also stated that it would make the same updates to the next editions of Medicare & You 
and Your Medicare Benefits. 
 
  Although CMS did not concur with our third and fourth recommendations, CMS stated 
that it would share the results of our portfolio with its contractors for their consideration 
as they develop their medical review workloads.  However, CMS stated that the 
contractors design their program integrity activities to most effectively target the highest 
priority issues in their jurisdictions given their limited resources.  In addition, CMS stated 
that it would support the program integrity activities its contractors identify that best meet 
CMSs goals for the program, including protecting the Medicare Trust Funds and limiting 
the burden on providers. 
 
Chiropractic Services Portfolio (A-09-16-02042)  18   
Office of Inspector General Response 
 
We strongly encourage CMS and its contractors to take actions to implement our third and 
fourth recommendations.  Implementing these recommendations would not only help 
Medicare reduce fraud, waste, and abuse related to chiropractic services but would also help 
CMS meet its goal of protecting the Medicare Trust Funds.  In addition, implementing these 
recommendations may help CMS (1) focus its program integrity resources on chiropractors 
with aberrant billing patterns or high service-denial rates and chiropractors who provide an 
excessive number of chiropractic services, which may be medically unnecessary, and 
(2) limit the burden on chiropractors without these characteristics. 
 
After reviewing CMSs comments, we refined our fourth recommendation and now 
recommend that CMS establish a threshold for the number of chiropractic services beyond 
which medical review would be required for additional services. 
   
Chiropractic Services Portfolio (A-09-16-02042)  19   
APPENDIX A: PRIOR OFFICE OF INSPECTOR GENERAL REPORTS 
 
 
Report Title  Report Number  Date Issued 
 
A Brooklyn Chiropractor Received Unallowable Medicare 
Payments for Chiropractic Services  A-02-13-01047  8/9/2017 
 
Hundreds of Millions in Medicare Payments for Chiropractic 
Services Did Not Comply With Medicare Requirements   A-09-14-02033  10/18/2016 
 
A Michigan Chiropractor Received Unallowable Medicare 
Payments for Chiropractic Services   A-07-14-01148  8/8/2016 
 
CMS Should Use Targeted Tactics To Curb Questionable and 
Inappropriate Payments for Chiropractic Services  OEI-01-14-00200  9/29/2015 
 
Alleviate Wellness Center Received Unallowable Medicare 
Payments for Chiropractic Services   A-09-14-02027  7/22/2015 
 
Advanced Chiropractic Services Received Unallowable 
Medicare Payments for Chiropractic Services  A-07-13-01128  5/27/2015 
 
Diep Chiropractic Wellness, Inc., Received Unallowable 
Medicare Payments for Chiropractic Services   A-09-12-02072  11/20/2013 
 
Inappropriate Medicare Payments for Chiropractic Services  OEI-07-07-00390  5/5/2009 
 
Chiropractic Services in the Medicare Program: Payment 
Vulnerability Analysis  OEI-09-02-00530  6/5/2005 
 
 
 
 
Chiropractic Services Portfolio (A-09-16-02042)  20  APPENDIX 8: CMS COMMENTS 

~~t.W.\'11"'1".$,, 
(~,,/-	
DEPARTMENT OF HEALTH & HUMAN SERVICES  Centers for Medicare & Medicaid Services 
200 Independence Avenue SW 
Washington, DC 20201 
DATE: 
SEP  2 8 2017 
TO: 	 Daniel R. Levinson 

Inspector Gene~ral  

FROM: 	 Seema Verma  ~ 

Administrator 

SUBJECT: 	 Office oflnspector General (OIG) Draft Report: Medicare Needs Better Controls 
to Prevent Fraud, Waste, and Abuse Related to Chiropractic Services (A-09-16
02042) 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the Office oflnspector General's (OTG) draft report on chiropractic services. CMS 
is committed to protecting the Medicare Trust founds by combatting fraud, waste, and abuse. To 
achieve this objective, CMS uses a comprehensive program integrity strategy to prevent 
improper payments through predictive analytics and provider education, among other tools, as 
well as to recoup overpayments that have already been made. 
CMS has implemented the Fraud Prevention System, to apply predictive analytic technology to 
identify aben-ant and suspicious billing patterns. The Fraud Prevention System runs predictive 
algorithms and other sophisticated analytics nationwide against all Medicare Fee-For-Service 
claims, including chiropractic claims. CMS utilizes the Fraud Prevention System as one means to 
target its investigative resources. When suspicious claims and providers are identified, an alert is 
generated for review by CMS' program integrity contractors and, ifwarranted, an investigation 
is initiated and appropriate administrative actions are considered. Currently, CMS has several 
chiropractic models within the Fraud Prevention System that analyze claims to detect potential 
fraud, waste, and abuse. Since CMS implemented the Fraud Prevention System in June 2011, 
more than $1.4 billion in inappropriate payments have been identified through new leads or 
contributions to existing investigations. Also, in fiscal year 201 5, CMS marked a national return
on-investment of$11 for every dollar the federal government spent on this program integrity 
system for all Medicare fee-for-service claims. 
Specific to chiropractic services, CMS has most recently promoted chiropractic-specific 
educational materials in March and July 2017 with the goal to reinforce education on the 
coverage and billing requirements for chiropractic services. These educational materials discuss 
billing requirements for spinal manipulation and proper use ofthe Active Treatment modifier, 
general chiropractic billing and Medicare coverage infotmation, and previous OIG report 
findings. The materials also clarify that Medicare does not provide payment for chiropractic 
maintenance therapy. In addition, since January 2013, CMS marketed the chiropractic benefit, 
Medicare chiropractic coverage criteria, compliance with Medicare program rules, and proper 
use ofthe Active Treatment modifier 10 different times to all providers. 
Chiropractic Services Portfolio (A -09-16-02042)  21  CMS also provides information on Medicare.gov and in written material, including the Medicare 
& You handbook and Your Medicare Benefits booklet, to educate beneficiaries on covered and 
non-covered Medicare services, including chiropractic services.  In addition to indicating that 
maintenance therapy is not covered, these resources clarify that both maintenance therapy and 
massage therapy are not covered chiropractic services. CMS recently updated Medicare.gov to 
highlight that acupuncture is also not a covered chiropractic service and to encourage 
beneficiaries to report suspected fraud by chiropractors. The handbook and booklet will be 
similarly updated in the future. 
While CMS shares OIG's concern regarding the chiropractic improper payment rate, it is 
important to note that improper payment amounts for chiropractic services account for less than 
one percent ofthe total improper payments in Medicare Fee-For-Service. CMS is committed to 
using its resources to most efficiently address fraud, waste, and abuse, and therefore considers 
multiple factors, including potential savings, when targeting program integrity resources for 
specific services. 
OIG's recommendations and CMS' responses are below. 
OIG Recommendation 
CMS should work with its contractors to educate chiropractors on the training materials that are 
available to them. 
CMS Response 
CMS concurs with this recommendation. CMS will continue to work with its contractors to 
promote education and training materials to chiropractors. 
OIG Recommendation 
CMS should educate beneficiaries on the types ofchiropractic services that are covered by 
Medicare, inform them that massage and acupuncture services are not covered by Medicare, and 
encourage them to report to CMS chiropractors who are providing non-Medicare-covered 
Services. 
CMS Response 
CMS concurs with this recommendation. CMS provides information on Medicare.gov and in 
written materials, including Medicare & You and Your Medicare Benefits, to educate 
beneficiaries on covered and non-covered Medicare services, including chiropractic services. 
These resources clarify that maintenance therapy and massage therapy are not covered 
chiropractic services. CMS recently updated Medicare.gov to highlight that acupuncture is also 
not a covered chiropractic service and to encourage beneficiaries to report suspected fraud by 
chiropractors. CMS will make the same updates to the next editions ofthe Medicare & You 
handbook and the Your Medicare Bene.fits booklet. 
OIG Recommendation 
CMS should identify chiropractors with aberrant billing patterns or high service-denial rates, 
select a statistically valid random sample of servi.ces provided by each chiropractor identified, 
review the medical records for the sampled services, estimate the amount overpaid to each 
chiropractor, and request that the chiropractors refund the amounts overpaid by Medicare. 
CMS Response 
Chiropractic Services Portfolio (A-09-16-02042)  22  CMS does not concur with this recommendation. CMS will share the results ofthis report with 
its contractors for their consideration as they develop their medical review workload. However, 
contractors design their program integrity activities to most effectively target the highest-priority 
issues in their jurisdictions given their limited resources, and, as stated above, improper payment 
amounts for chiropractic services account for less than one percent of the total improper 
payments in Medicare Fee-For-Service. CMS will support the program integrity activities our 
contractors identify that best meet CMS' goals for the program, including protecting the 
Medicare Trust Funds and limiting burden on providers. 
OIG Recommendation 
CMS should establish a threshold for the number ofchiropractic services that a beneficiary may 
receive per year and require medical review for services in excess ofthat threshold. 
CMS Response 
CMS does not concur with this recommendation. CMS will share the results of this report with 
its contractors for their consideration as they develop their medical review workload. However, 
contractors design their program integrity activities to most effectively target the highest-priority 
issues in their jurisdictions given their limited resources. CMS is mindful ofprioritizing the 
doctor-patient relationship while supporting the program integrity activities our contractors 
identify that best meet CMS' goals for the program, including protecting the Medicare Trust 
Funds and limiting burden on providers. 
Chiropractic Services Portfolio (A-09-16-02042)  23   
ENDNOTES 
 
 
 
1 In this portfolio, a chiropractic service refers to a single treatment for subluxation of the spine. 
 
2 Social Security Act  1862(a)(1)(A). 
 
3 CMSs Medicare Benefit Policy Manual, Pub. No. 100-02, chapter 15,  30.5(B). 
 
4 Subluxation is a motion segment, in which alignment, movement integrity, and/or physiological function of the 
spine are altered although contact between joint surfaces remains intact (Medicare Benefit Policy Manual, 
chapter 15,  240.1.2). 
 
5 Medicare Benefit Policy Manual, chapter 15,  240.1.3. 
 
6 Medicare guidance states that either the date of the initial treatment or the date of exacerbation of the existing 
condition must be included on a claim for chiropractic services (Medicare Claims Processing Manual, Pub. No. 
100-04, chapter 12,  220.C). 
 
7 An edit is programming within the standard claims processing system that selects certain claims; evaluates or 
compares information on the selected claims or another accessible source; and, depending on the evaluation, takes 
action on the claims, such as paying them in full, paying them in part, or suspending them for manual review. 
 
8 Medicare Access and CHIP Reauthorization Act of 2015, P.L. No. 114-10 (enacted Apr. 16, 2015),  514.  CHIP 
stands for the Childrens Health Insurance Program.  
 
9 The MACRA does not define aberrant billing patterns.   
 
10 MACRA  514(a).  As of July 5, 2017, CMS had not implemented the prior-authorization process. 
 
11 MACRA  514(b).  In 2015, CMS developed a public broadcast entitled Improving the Documentation of 
Chiropractic Services to implement the education and training program required by the MACRA. 
 
12 CMSs Supplementary Appendices for the Medicare Fee-for-Service Improper Payment Reports for 20102015.   
 
13 Medicare requires beneficiaries to pay a coinsurance amount equal to 20 percent of the amount allowed by 
Medicare for chiropractic services and pays the chiropractor the remaining 80 percent (42 CFR  489.30(b) and 
410.152(b)).  However, not all beneficiaries pay out-of-pocket for coinsurance.  Some beneficiaries have secondary 
insurance coverage (e.g., Medicaid) that will pay the coinsurance.   
 
14 Chiropractic Services in the Medicare Program: Payment Vulnerability Analysis (OEI-09-02-00530), issued 
June 5, 2005. 
 
15 Inappropriate Medicare Payments for Chiropractic Services (OEI-07-07-00390), issued May 5, 2009. 
 
16 Diep Chiropractic Wellness, Inc., Received Unallowable Medicare Payments for Chiropractic Services 
(A-09-12-02072), issued November 20, 2013.  Advanced Chiropractic Services Received Unallowable Medicare 
Payments for Chiropractic Services (A-07-13-01128), issued May 27, 2015.  Alleviate Wellness Center Received 
Unallowable Medicare Payments for Chiropractic Services (A-09-14-02027), issued July 22, 2015.  A Michigan 
Chiropractor Received Unallowable Medicare Payments for Chiropractic Services (A-07-14-01148), issued 
August 8, 2016.  A Brooklyn Chiropractor Received Unallowable Medicare Payments for Chiropractic Services 
(A-02-13-01047), issued August 9, 2017. 
 
Chiropractic Services Portfolio (A-09-16-02042)  24   
                                                                                                                                                                                           
17 CMS Should Use Targeted Tactics To Curb Questionable and Inappropriate Payments for Chiropractic Services 
(OEI-01-14-00200), issued September 29, 2015.  A medical record review was not conducted to determine whether 
the services were medically necessary or billed with the correct procedure code.   
 
18 Hundreds of Millions in Medicare Payments for Chiropractic Services Did Not Comply With Medicare 
Requirements (A-09-14-02033), issued October 18, 2016.  
 
19 Revised Requirements for Chiropractic Billing of Active/Corrective Treatment and Maintenance Therapy, full 
replacement of Change Request (CR) 3063, CMS Transmittal 23, CR 3449, Oct. 8, 2004. 
 
20 A Local Coverage Determination is a decision by a Medicare contractor of whether to cover a particular item or 
service on a contractor-wide basis in accordance with section 1862(a)(1)(A) of the Social Security Act. 
 
21 OIG exclusions are not limited to Medicare.  Excluded individuals and entities are excluded from participation in 
all Federal health care programs, including Medicare, Medicaid, and all other plans and programs that provide health 
care benefits funded directly or indirectly by the United States (other than the Federal Employees Health Benefits 
program). 
 
22 OIG has the authority to exclude individuals and entities from federally funded health care programs and 
maintains a list of all currently excluded individuals and entities called the List of Excluded Individuals and Entities 
(LEIE).  The LEIE database on the OIG website (https://oig.hhs.gov/exclusions/exclusions_list.asp) contains all 
exclusions in effect.  We reviewed the database that was updated in December 2016. 
 
23 Medicare Benefit Policy Manual, chapter 15,  30.5(B). 
 
24 CMSs Medicare Learning Network factsheet Misinformation on Chiropractic Services (ICN 006953), issued 
March 2015.  This factsheet was intended to provide a general summary of Medicare coverage of chiropractic 
services, not to replace either Federal law or regulations. 
 
25 Inappropriate Medicare Payments for Chiropractic Services (OEI-07-07-00390), issued May 5, 2009. 
 
26 CMS Should Use Targeted Tactics To Curb Questionable and Inappropriate Payments for Chiropractic Services 
(OEI-01-14-00200), issued September 29, 2015.  A similar recommendation was made in the report entitled 
Hundreds of Millions in Medicare Payments for Chiropractic Services Did Not Comply With Medicare 
Requirements (A-09-14-02033), issued October 18, 2016. 
 
27 Hundreds of Millions in Medicare Payments for Chiropractic Services Did Not Comply With Medicare 
Requirements (A-09-14-02033), issued October 18, 2016. 
 
28 Hundreds of Millions in Medicare Payments for Chiropractic Services Did Not Comply With Medicare 
Requirements (A-09-14-02033), issued October 18, 2016. 
 
29 CMS develops NCDs to describe the circumstances in which Medicare will cover specific services, procedures, or 
technologies on a national basis. 
 
30 Chiropractic Services in the Medicare Program: Payment Vulnerability Analysis (OEI-09-02-00530), issued 
June 5, 2005. 
 
31 Hundreds of Millions in Medicare Payments for Chiropractic Services Did Not Comply With Medicare 
Requirements (A-09-14-02033), issued October 18, 2016. 
Chiropractic Services Portfolio (A-09-16-02042)  25