We Get Letters & E-Mail

Auditing Your Medicare Article

Dear Editor:

The American Chiropractic Association's Medicare Committee read with interest the article titled, "Understanding Medicare RAC Audits," which appeared in the July 15, 2011 issue of Dynamic Chiropractic. Given the recent increase in audits conducted on doctors of chiropractic by the Centers for Medicare and Medicaid Services (CMS) and its contractors, the ACA believes it is crucial that doctors are provided with assistance and resources to help them through the difficult medical documentation review and audit process. Unfortunately, the information included in "Understanding Medicare RAC Audits" contained misinformation which may serve only to increase concern and confusion within the profession.

Information that appeared in "Understanding Medicare RAC Audits" could lead readers to believe Recovery Audit Contractors (RACs) are charged with requesting records in an effort to identify any type of error. The authors state, "Typically, a RAC would contact your practice by letter, requesting that you send records to their attention for review. What the RAC is doing is looking at records for which you have already been reimbursed to see where payments may have been made that are not substantiated by your documentation techniques." This is simply not an accurate depiction of how RACs operate.

RACs are required to submit to CMS a list of specific issues they wish to investigate. CMS then reviews the list and informs the RAC of the issues they may proceed in reviewing. RACs are then required to post online all the issues they are currently investigating. It is extremely important to note that, to date, no RACs have specifically requested to review the billing of chiropractic manipulative treatment codes (a complete list of the RACs and their issues currently under review is included below). It is also important to note that there are two types of RAC reviews. The first is automated and the second is complex. The majority of issues currently under investigation by RACs that would apply to Medicare Part B providers are automated. That means no additional documentation needs to be submitted to the RAC for the review. For complex reviews, RACs will request documentation. In "Understanding Medicare RAC Audits," no information was included regarding this important distinction. To say that RACs request records and search to identify any type of error is simply not accurate.

For automated RAC reviews, the RAC reviews claims data to determine if an error has occurred. Automated review issues that have been approved for investigation by CMS include such claims errors as: submitting duplicate claims for the same patient for the same date of service, billing procedures for an adult that are only intended to be reported for children, or billing multiple times for procedures that are only performed once in a lifetime. For complex reviews, the RAC will request documentation regarding a specific issue approved for review. As was noted in "Understanding Medicare RAC Audits," doctors have appeal rights in response to RAC determinations.

While it is accurate that the companies hired to conduct RAC audits are paid when they recoup funds, it was not noted in the article that RAC auditors are also tasked with determining if underpayments have been made. CMS' RAC program went nationwide in October 2009 and, since that time, RAC contractors have identified $52.6 million in Medicare underpayments. Following the identification of underpayments, providers were paid for those services.

While the process of financially rewarding contractors for identifying overpayments concerns many doctors, an incomplete picture of the purpose of RACs is depicted when it is not noted that these contractors are also concerned with underpayments. It should also be noted that if a RAC determination is overruled at any level of an appeal, the RAC must return the contingency fee they were awarded.

While we are concerned with some of the information included in the "Understanding Medicare RAC Audits" article, the ACA's Medicare Committee could not agree more with the statement made in the article regarding the need to appeal determinations that are inaccurate. The ACA provides information and resources to assist providers in the appeal process; we encourage doctors to visit www.acatoday.org/medicare for more information.

Issues Approved by RAC Contractors:

Region A (Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont)

Diversified Collection Services (DCS) Issues Approved for Review: www.dcsrac.com/IssuesUnderReview.aspx

Region B (Illinois, Minnesota, Wisconsin, Indiana, Michigan, Kentucky, Ohio)

CGI Issues Approved for Review: http://racb.cgi.com/Issues.aspx

Region C (Alabama, Arizona, Colorado, Florida, Georgia, Louisiana, Mississippi, North Carolina, New Mexico, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia, Puerto Rico and the U.S. Virgin Islands)

Connolly, Inc. Issues Approved for Review: www.connolly.com/healthcare/pages/ApprovedIssues.aspx

Region D (Alaska, Arizona, California, Hawaii, Iowa, Idaho, Kansas, Missouri, Montana, North Dakota, Nebraska, Nevada, Oregon, South Dakota, Utah, Washington, Wyoming, Guam, American Samoa and Northern Marianas)

HealthDataInsights, Inc. Issues Approved for Review: https://racinfo.healthdatainsights.com/home.aspx?ReturnUrl=%2f

Ritch Miller, DC
Chairman, ACA
Medicare Committee

A More Suitable Name for High-Velocity Manipulation?

Dear Editor:

I propose that as a profession, we endeavor to make a change in the nomenclature of one particular procedure – what's often known as high-velocity manipulation or adjustment. Calling something "high-velocity" makes it sound more violent than it actually is. An equally relevant feature of this type of manual procedure is that the duration of the impulse delivered is brief. Doesn't brief-impulse manipulation (or adjustment) sound a lot better?

Ronald Lavine, DC
New York, N.Y.

Editor's Note: The following two letters to the editor are in response to Dr. James Edwards' Aug. 26, 2011 column, "Seeing Around the Corner: Drugs Will Harm Your Practice."

Why Pharmaceutical Privileges Won't Harm Your Practice

Dear Editor:

I'd like to rebut Dr. Edwards' assumptions regarding the potential inclusion of pharmaceuticals in chiropractic practice:

1. Our patients don't come to see us because we're "nondrug, nonsurgical." In fact, many of them are unclear about our scope. I am sure we've all been asked about whether we can help with prescriptions or for advice about other options and weaning off drugs; neither of which we can do currently in most states, but which would enable us to better serve our patients..
2. The revenue from a wider variety of possible diagnoses and modalities would cover the cost of increasing our malpractice coverage, and like MDs who don't do in-office procedures and are not requesting coverage for that, doctors who choose not to prescribe will not be charged coverage for those services.
3. I have yet to meet an advanced-practice doctor who denigrates any chiropractic colleague in any way. Just like MDs who pick and choose what they wish to practice from a very broad scope, chiropractors would be free to do the same. One is not "less" because they don't prescribe, any more than I am "less" because I don't have a state-of-the-art laser or decompression machine in my office.
4. In the future, just as in the present, doctors will continue to select their CE according to their focus and interest. Many states now require ongoing education in documentation (My home state of Colorado is one) and as Medicare documentation is the "gold standard" that insurance companies adhere to, it seem reasonable that if a documentation seminar covers the Medicare requirements, by definition it covers all the rest. Considering that evaluation of documentation skills among health care professions often shows chiropractic to be lacking in this regard, I am happy to see a requirement that will bring us to an industry standard.
5. Medical doctors cross-refer constantly and are not territorial with their patients. Drugs are not the only component of their "bag" any more than HIO adjustments are the only component in ours. We will continue to see referrals from MDs if they perceive a value to their patients in such a referral. And if Dr. Edwards had attended the APC training, he would have seen that it builds on our education in biochemistry, physiology and toxicology, and hardly qualifies as a weekend seminar!
6. A patient dying as the result of a "chiropractic prescription" would likely not be any more noteworthy than a patient dying from a "medical prescription." (Fortunately or unfortunately, Big Pharma doesn't like bad publicity.) We don't hear much about the adverse effects of drugs (not that it's a good thing that we don't). With our "less is more" orientation to drugs in general, I think that those incidents would be less likely than in the current medical model.

Cathlynn Groh, DC-APC
Denver, Colo.

How Can We Truly Serve the Public by Adding Drugs?

Dear Editor:

I am DC student (Tri 4) at National University of Health Sciences. I recently read Dr. James Edwards' article, "Seeing Around the Corner: Drugs Will Harm Your Practice." I have also heard NUHS President Dr. Winterstein speak on occasion, but I must say that I welcome this article. While I appreciate Dr. Winterstein's experience and knowledge, I find that his position glosses over the tantamount dangers and failures of drugs to promote health. [Read Dr. Winterstein's recent article on the drug issue, "Best for the Profession or Best for the Public? in the June 3 issue.]

As strides are made toward prescribing rights and incorporation of drugs into chiro practice, the traditional chiropractic skepticism toward drugs evaporates. This waning skepticism is exacerbated by the drug culture that new DCs and students are raised in. Sadly, many of my colleagues don't see anything wrong with drugs, let alone prescribing them. Many of them have been vaccinated before they could walk and have taken an antibiotic for every illness conceivable – even if it was viral. Some have been placed on dangerous psych drugs for school and may still be on them now, thinking they need them for their studies. Many take NSAIDs for most aches and pains, and though they believe in chiropractic manipulation, they have grown up in a drug culture and thus cannot see medicine without them.

It is hard to communicate the dangers of drugs and prescribing them to the latest generation of would-be chiros, but that does not mean it should not be done. I believe it is more important now than ever for chiropractors to maintain their traditional skepticism toward drugs and continue to champion methods of health care that enlist the body's endemic recuperative agencies for health. With the increasing deaths and health complications from prescription drugs, can chiropractors really serve the public by adding them to their treatment protocols?

Timothy R. Perenich
Tri 4 Student, NUHS