A task force comprised of officials from four national chiropractic organizations has released a comprehensive action plan in response to a series of problems identified by the Department of Health and Human Services' Office of the Inspector General.
The Inspector General's report was published in June 2005, using a random sample of Medicare claims data from 2001. The report found that while documentation errors relating to Medicare claims were a common occurrence among all types of health care providers, doctors of chiropractic had the highest error rate compared to other provider groups, resulting in approximately $285 million in "improper payments" to doctors of chiropractic.1,2 So egregious were the errors, in fact, that the OIG report concluded: "Based on the volume of medically unnecessary, undocumented, and noncovered services allowed, chiropractic services represent a significant vulnerability for the Medicare program" (emphasis added).
Realizing the seriousness of the report and the negative light in which chiropractic was being portrayed resultant to the report's findings, officials from the ACA, the Association of Chiropractic Colleges, the Congress of Chiropractic State Associations and the Federation of Chiropractic Licensing Boards combined their resources to develop a plan that would not only address the OIG's concerns, but also would significantly reduce error rates and improve the claims documentation process for all practicing doctors of chiropractic. After five months of deliberation, the organizations reached common ground on a set of direct, tangible steps that can be taken in the immediate future, and formulated them into what the task force believes is a comprehensive plan of action.
Cooperation, Coordinated Effort Keys to Plan's Success
The action plan contains more than a dozen goals and deadlines, many of which are scheduled to take place in the next few weeks (see "Proposed Action Plan Timeline" below). It relies on the efforts of all four organizations to tackle the issue of reducing Medicare documentation errors from a variety of perspectives, with each organization playing an important role in the plan's overall success. Significant emphasis will be placed on the role of state licensing bodies in developing mandatory continuing education courses in documentation to improve Medicare compliance.
"We need to do more, and we all need to be part of the solution," remarked FCLB President Dr. Ed Weathersby. "The licensing boards need to take a closer look at the continuing education and ethical issues involved in solving this problem."
Chiropractic colleges will participate in the plan by reviewing their current curricula to ensure that students receive proper training on documentation for care considered a "medical necessity." According to ACC President Frank Zolli, DC, making sure that students are qualified to document the care they administer to patients "appears to be an education and training issue."
While the ACC will address training in appropriate documentation procedures for students, COCSA member associations will work with the ACC, ACA and other agencies to offer more uniform continuing education programs on billing and record-keeping for practicing doctors of chiropractic. The task force will work to develop "model" content for such programs, and plans to have a core program unveiled by May 2006.
COCSA President Steve Simonetti, DC, pledged that state chiropractic associations will play a major role in the implementation of the new continuing education programs. "State associations will lead the effort by informing doctors of chiropractic about the problem, and then by providing opportunities for DCs and their staff to receive proper training to eradicate these filing errors," Simonetti said.
To ensure that the continuing education component of the action plan remains in motion, the ACA will make copies of its Clinical Documentation Manual available to all chiropractic colleges, universities, state associations and individual doctors of chiropractic at cost for a 12-month period. The manual contains more than 30 documentation recommendations and is intended to help DCs better document their services while ensuring high-quality patient care.
"The first step has been taken with development of the Clinical Documentation Manual," ACA President Richard Brassard, DC, proclaimed. "Now we must turn every practitioner's attention to the details involved."
In addition to tackling the issue of erroneous Medicare documentation on an intraprofessional level, the task force also will look outside the profession for guidance on issues related to insurance carrier administration. Specifically, the task force plans on working directly with representatives from designated Medicare carriers to identify ways in which the processing of chiropractic Medicare claims can be standardized and improved.
The complete proposed action plan is currently available on the ACA Web site: www.acatoday.com/government/medicare/docs/OIG_TaskForce_ActionPlan.pdf.
Proposed Action Plan Timeline
Establishment of Formal Task Force
- No later than Jan. 31, 2006, the ACA, ACC, FCLB and COCSA will formally establish a Chiropractic Documentation Task Force to monitor implementation of the action plan, students receive proper training on documentation for care considered a "medical necessity." According to ACC President Frank Zolli, DC, making sure that students are qualified to document the care they administer to patients "appears to be an education and training issue."
Coding Errors and Other Documentation Clarifications
- No later than Jan. 31, 2006, representatives of the ACA, ACC, COCSA and FCLB will initiate a "sample claims analysis" work session with CMS and its designated representatives and carriers to discern specific areas of common confusion and error regarding documentation of chiropractic Medicare claims.
Regulatory Involvement
- By Jan. 31, 2006, the FCLB will deliver educational materials to its member boards to inform licensed doctors of chiropractic about the seriousness of the OIG report. Specific guidance for claims submitted to CMS will be included in the materials.
- By March 15, 2006, the FCLB will complete a survey of its U.S. member boards to ascertain the level of regulatory autonomy boards have in requiring specific continuing education hours in required subjects as a condition for relicensure.
- In May 2006, at its Annual Congress, the FCLB will hold a plenary session to educate licensing boards about ways they can address the issues raised in the OIG report, including a preview of the model postgraduate continuing education program as developed by the ACC.
- In addition, during the Annual Congress the FCLB's board of directors will present to its delegate body a resolution that formally recommends all U.S. jurisdictions exercise the full scope of their available authority to require continuing education in documentation and claims submission, specifically as it relates to Medicare. The resolution also will recommend that doctors of chiropractic complete those continuing education courses within 12 months from the date a state licensing board implements such a requirement.
Development of Chiropractic College Curriculum on Documentation and Continuing Education Program
- No later than March 20, 2006, the Association of Chiropractic Colleges (ACC) will present a preliminary draft of the key components for appropriate chiropractic college curricula on record-keeping and billing to its member institutions at the annual ACC-Research Agenda Conference, or ACC-RAC. Any necessary new proposals and/or changes to current curricula will be implemented by the fall of 2006.
- No later than May 1, 2006, draft curriculum for a postgraduate educational program to address record-keeping and billing issues will be developed by ACC member schools, along with the ACA, COCSA and FCLB (and possibly CMS). The program will then be presented at the FCLB's Annual Congress.
Interim Workshops on CMS Documentation Compliance
- The task force will support interim efforts by other parties to present educational workshops about the OIG report and steps necessary to identify issues of documentation and related areas. The task force also will provide components of an acceptable curriculum for such workshops. The first major national workshop will be held at the National Chiropractic Legislative Conference in March 2006.
Outreach Campaign
- In January 2006, the organizations comprising the task force will publish and distribute "An Open Letter to the Chiropractic Health Care Profession," which will apprise the profession of the OIG report and the need to address proper CMS documentation. The letter will be distributed to all chiropractic organizations, colleges, regulatory boards, media outlets and other venues, and will appear in the ACA News a minimum of six times within the next 12 months.
Accountability
- No later than Sept. 30, 2006, the task force will issue a formal written report to CMS, OIG, the U.S. Congress and the chiropractic profession; interim reports may be issued as circumstances warrant.
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