Fraud and Abuse Medical Review Benchmarks

RESOLVED, that the American Chiropractic Association considers the attached "Fraud and Abuse Medical Review Benchmarks" as official policy:

Public concern over the incidence of provider fraud and its impact on quality of care and higher insurance premiums is increasing. This is creating heightened accountability for both insurers and providers in the area of fraud and abuse control. Even certain state laws require insurers to implement anti-fraud programs as part of their regulatory compliance. Based on these market conditions, it is to the advantage of both the insurance industry and all health care professionals to cooperatively identify and eliminate potentially fraudulent and abusive activities due to its negative impact on the insuring public and the image of all health care professionals.

To this end, the American Chiropractic Association recommends a policy statement founded on the following business approach:

Fraud Opposition: In addition to cost savings, public messages around fraud/abuse elimination need to reflect insurer and provider interest in bettering the healthcare delivery system to ensure the provision of quality care for insured patients.

Fraud Definition: Certain criteria must exist to consider or otherwise reference a situation as potentially fraudulent. Fraud is defined as an intentional misrepresentation where these conditions are present:
  • There must be a cause of deception.
  • The act or acts must show an intentional misrepresentation of fact.
  • The provider stands to gain financially from the deception and misrepresentation.
Abuse Definition: Abuse differs from fraud in that it describes incidents or practices of providers that are inconsistent with accepted sound clinical, business or fiscal practices (including but not limited to excessive or unnecessary care, improper business practices, poor clinical documentation, coding and billing mistakes) but that are not knowingly or intentionally misrepresented facts to obtain payment.

Fraud and Abuse Identification: Retrospective reviews referred for investigation require a sound basis for suspecting fraud/abuse and should not target any profession. A professional opinion by a peer in the same state and in the same specialty may be indicated.

Data mining, pattern software or other methodologies to identify potential fraud/abuse can be used to show deviations from the standard of care within the community. The investigation of the cause behind the deviation from the standard of care will take into account the accepted practices for the provider type identified.

Data considered to represent outlier behavior may not represent wrongdoing and requires an explanation from the treating provider. The case mix complexity needs to be considered as do other patient complications including condition, age, co-morbidity and severity of injury etc.

Post payment review/retrospective utilization review or other fraud and abuse audits should be based on the insurers' policies and procedures that were in effect at the time the services were provided .

No financial incentive may exist for a fraud/abuse referral, investigation or recovery however, it is understood that insurers must cooperate with state and federal agencies as requested. These policies and procedures should be arrived at with peer input and in a scientifically and legally defensible manner, and should be clearly communicated to providers.

License and Billing Requirements: Doctors of chiropractic should hold a current license in good standing and use proper codes and billing intent for both diagnosis (ICD-CM) and treatment codes (CPT). Treating providers should direct patient care including the ordering of tests and other services subject to the medical necessity for each patient. A provider should review billings before they are submitted to insurers to ensure there is supporting clinical documentation for all services and treatments.

Qualifications for Fraud/Abuse Reviewers and Investigators: Internal insurance reviewers and field investigators and coordinators should be knowledgeable in the chiropractic field and understand specific CPT coding used by doctors of chiropractic including Evaluation and Management, Physical Therapy and Rehabilitative Services, Manipulation and Diagnostic Imaging. Attention to the state scope of practice is needed. Specific experience in a variety of health care related fields is recommended including but not limited to:

  • Terminology and Abbreviations
  • Care Definitions
  • Content and Interpretation of Clinical Records
  • Claim Administration Policy and Procedure
  • Fair-minded Medical Review Practices
  • Compliance with State Claim Handling Regulatory Requirements
  • Privacy, Disclosure and Confidentiality Protection

Communications Surrounding Fraud/Abuse Investigations: Insurer policies may be superimposed by federal or state criminal policy for fraud actions, however, for abuse situations, communications should not intimidate the provider on any level, during or in the course of an investigative procedure, including but not limited to the provision of necessary care for the patient. Dialog should be directly between the insurer and the provider and not involve the patient, office staff or other parties unless those parties have filed a formal inquiry with the insurer as to the nature of a potentially abusive situation. Other formalities need to exist including:

  • No unannounced on-site visits and the use of best efforts to find a mutually agreeable time to meet.
  • Adequate notice to the provider about an emerging abuse or a subsequent investigation, including the rationale for the investigation.
  • Notification to be provided no longer than 6 months following the receipt of the final bill.
  • Arranging for payment of billings not in question.
  • Provision for provider to submit supplemental information and to contest the findings.
  • Periodic (30 day) status of the investigation sent to the provider.
  • Written final investigative report to be sent to the provider outlining the areas of disparity.
  • Willingness to resolve conflict in a reasonable time frame.
  • Access to the investigator for discussion purposes.

The treating provider should cooperate in the submission of records and be responsive to the above conditions in an effort to resolve the issue at hand in a reasonable time frame. Investigative staff and treating providers will conduct themselves in a professional way throughout the process.

Reimbursement and Recovery: When the insurer, outside investigative agency and the treating provider agree funds are recoverable, it will be subject to the following terms:

  • Funds may be recoverable for 3 months, prior to the time of audit notification to the provider.
  • For amounts not to exceed the plan reimbursement level for said services.
  • For only those services that are in question on actual claim payouts.
  • Less services that may not have been billed the provider can document.
  • Less reasonable copying fees incurred by the provider.

All efforts should be made to resolve the agreed upon financial arrangement within 30 days unless otherwise agreed to by both parties.

Any situations that may arise that are not covered under this document should be approached with a similar philosophy of direct and open dialog. Both the chiropractic profession and payer industry should attempt through various forums to find common ground to eliminate fraud.

(Ratified by the House of Delegates, September 2004)