What payers should know about chiropractic fraud, waste and abuse

An exclusive interview with Dan Bowerman

FierceHealthPayer: Anti-Fraud spoke to Daniel S. Bowerman, D.C., to learn about chiropractic fraud and overutilization. Bowerman (pictured) has been a practicing chiropractor since 1978. He's a principal at Expert Opinions Consulting in Philadelphia, which provides expertise in civil and criminal proceedings, and he served as a health plan medical director for 13 years.

FierceHealthPayer: Anti-Fraud: What are some of the major schemes run by rogue chiropractors?

Dan Bowerman: Many emerging schemes are recycled problems, and they follow reimbursement. Services that pay a nominal amount tend to be billed excessively. One example is billing for the American Medical Association's Current Procedural Terminology code 98943, extra-spinal manipulation. Utilization of this code has become a national endemic in the last eight years.

This procedure involves the shoulder, wrist, elbow, knee or ankle. Providers began billing this code in addition to regular manipulation charges to generate higher allowances. Strictly speaking, you don't expect to see billing for both these codes for every patient at every visit.

I've also seen claims for services not rendered or services that don't meet reimbursement thresholds. Then there's unbundling, or billing for component parts of an evaluation on separate days.

Upcoding is a problem. We see the highest levels of services frequently claimed for manipulation services and electrical muscle stimulation.

I've also seen misrepresented therapeutic magnetic resonance services. The device used for these services is classified by the Food and Drug Administration as a transcutaneous electrical nerve stimulation (TENS) unit. One provider billed a nonspecific code for magnetic resonance imaging and received payments of more than $2,000 per claim. Another example of misrepresented services is traction billed as surgical decompression.  

There's also misuse and overuse of services. If it takes a provider one week to get something done but billings are for three weeks to four weeks of care, for example, that's an issue. And when all patients receive the same mix of services, that's generally not considered medically necessary.

An exploding utilization problem is overuse of durable medical equipment (DME). Several vendors sell assistance in getting chiropractors licenses to become DME distributors. This can be lucrative. But DME use should be an exception, not the rule. A trend of billing for lower back braces costing up to $1,000 each has appeared.

Further, I worked on a criminal case involving straw practice ownership. The provider hired someone licensed to perform services, but that person wasn't present in the office at the time of care. There's also masked practice ownership. I testified in a case where a nonlicensed, nonclinical individual used a practitioner's national provider identifier to bill $1.8 million in claims. He was sentenced to five years in federal prison.