The American Chiropractic Association (ACA) recently requested a meeting with the Health Care Financing Administration (HCFA) after learning that the Office of Inspector General (OIG) had recommended that chiropractic care of Medicare patients continue to be screened (reviewed) after 12 visits. Even though the OIG's report has yet to be published, ACA's political presence gave the OIG early warning of their resolve.
On October 19, 1999, a meeting was held between a seven-person ACA delegation and an equal contingent from HCFA and the OIG (two on speaker phone). The meeting was the culmination of over three years of effort by the ACA. During that time, there have been many meetings among chiropractic leaders to develop a chiropractic consensus on the Medicare review standard. That consensus was provided in a report submitted to HCFA on October 9, 1998 by ACA on behalf of the chiropractic profession.
Dr. Jerilynn Kaibel, ACA spokesperson at the HCFA meeting.The need for a chiropractic consensus on Medicare was sparked by changes to the Medicare program prompted by the 1997 Balanced Budget Act (BBA). The BBA eliminated x-rays as the sole means to demonstrate existence of a subluxation to justify coverage (effective Jan. 1, 2000). The BBA also directed the secretary of Health and Human Services (HHS) to develop and implement new chiropractic utilization guidelines. HCFA has been mandated to complete the new Medicare guidelines for implementation in 2000.
The ACA recommendations to HCFA made it very clear that the chiropractic profession does not need any kind of screen on utilization; that doctors of chiropractic are responsible and capable of discerning and documenting clinical necessity. But given that HCFA has mandated a screening of chiropractic care of Medicare patients, the chiropractic consensus is that an optional review at 18 initial visits with a mandatory review after an additional six visits would address the needs of most Medicare patients and provide an adequate screening process.
The ACA went into the HCFA meeting on one positive note. The Medicare carrier medical directors who reviewed the ACA recommendations agreed with the 18 initial chiropractic visits, but recommended a mandatory review at that level. This was an encouraging sign, given the fact that 29 of the 50 Medicare carriers have a 12-chiropractic-visit screen policy currently in place.
The meeting with the HCFA officials was open and direct, although neither tape recording nor photography was allowed during the proceedings. Along with Dynamic Chiropractic, several other chiropractic organizations sent representatives to sit in on the meeting: the Journal of Clinical Chiropractic; the World Chiropractic Alliance; Chiropractic Biophysics; and the Council on Chiropractic Practice.
Jeff Kang, MD, director of HCFA's Office of Program Integrity, chaired the meeting. Jerilynn Kaibel, DC, ACA District VII Governor and member of the HHS Practicing Physician Advisory Council was spokesperson for the ACA delegation. Assisting Dr. Kaibel were Christine Goerts-Hegesweiller,DC,PhD, an ACA consultant, and Al Dobson, PhD, of The Lewin Group.
During the meeting, ACA representatives reiterated their opposition to any specific screening parameter for chiropractic services under Medicare, but urged that if a "screen" is adopted by HCFA it should allow for at least 18 treatments per year before taking effect. ACA representatives presented statistics of chiropractic Medicare visits in 1997 and background information to counter the OIG argument and bolster the 18-visit screen initiative. The Lewin Group, a nationally known and respected Washington, D.C. health care consulting firm, was contracted by the ACA to provide the statistics. Those statistics revealed that Medicare patients on average receive only 10.6 chiropractic visits per year. In states where the review screen is at 30 visits and higher, the average number of visits is not appreciably higher.
When told that the current 12-visit review screen has effectively become in many cases an illegal capitation, the OIG representatives appeared surprised. It was an aspect of the situation they were apparently unaware of.
But at the eleventh hour, the OIG disagreed with the chiropractic consensus and that of the Medicare carrier medical directors. In a report that at press time still hasn't been made public, the OIG's suggestion was for an optional review at 12 visits: essentially where it is now.
In a follow-up letter to Dr. Kang, Dr. Kaibel wrote:
"If such a (screening) procedure is to be adopted by HCFA, we believe it should be an effective means to screen for medical necessity based on clinical criteria and not serve to deny appropriate beneficiary access to covered care. We believe that the 12-visit utilization screening number proposed by the Office of Inspector General fails on both of these bases. The 12-visit screen has no clinical foundation, but rather, is a relic of the historical practice of 29 carriers. The fact that many of the carriers are moving away from the 12-visit screen is, in our view, evidence that the 12-visit screen is outmoded, and it is time to get things right."
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
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