In the final part of this series we look into how the office of the inspector general responded to the 2015 report. While there is one recommendation that the OIG did not agree with you can see how they agreed with most of the recommendations overall. This is really one of the documents that shows the birth of the MACRA standards.
CMS did not concur with our first recommendation and concurred with our other four recommendations. CMS did not concur with our recommendation to establish a more reliable control for identifying active treatment, citing significant obstacles to doing so. CMS stated that it will implement prior authorization medical review required by MACRA, which it believes will help address the concerns we identified. However, we are uncertain that this adequately addresses our concerns with payments for maintenance therapy. The medical review under MACRA targets a narrow group of chiropractors with aberrant billing or high rates of claim denial, who are not necessarily chiropractors receiving payments for maintenance therapy.
CMS concurred with our recommendation to develop and use measures to identify questionable payments for chiropractic services. CMS stated that it will reexamine its models for identifying chiropractic fraud, waste, and abuse and that it will look for opportunities to improve or extend these models.
CMS concurred with our recommendation to take appropriate action on the chiropractors with questionable payments. CMS stated that it will consider chiropractors we identified when it develops postpayment review under MACRA. However, postpayment review will apply to chiropractic services provided on or after January 1, 2017. CMS’s approach may delay appropriate action on chiropractors we identified as having high questionable payments, many of whom were paid millions of dollars for questionable claims for several years. In the near term, we urge CMS to consider the approaches that we suggest in our recommendation and determine the appropriate course of action.
CMS concurred with our recommendation to collect overpayments for inappropriately paid claims. CMS stated that it will analyze the claims we provide, determine which to review more closely, and take appropriate action as needed. We are forwarding to CMS by separate memorandum the claims that we have already identified as not meeting Medicare’s coverage requirements to facilitate overpayment recovery.
CMS concurred with our recommendation to ensure that claims are paid only for Medicare-covered diagnoses. CMS stated it will work with the MACs to ensure that claims are paid only for the diagnosis codes that meet Medicare coverage requirements.
All information in the article is from Suzanne Murrin Deputy Inspector General for Evaluation and Inspections September 2015 OEI-01-14-00200