The Hidden Dangers of Chiropractic Fraud

Chiropractic fraud. It's a topic that's been lurking in the shadows of healthcare for years, and while it's often dismissed as an isolated issue, the truth is, it’s far more widespread than many realize. So, what’s going on behind the scenes in the world of chiropractic care, and why should we all be paying attention?

Let’s break it down.

??The Epidemic of Chiro Fraud

Chiropractic fraud is a complex issue that includes everything from misusing modifiers to billing for services that were never rendered. It’s a practice that not only cheats the system but also puts patients at risk by encouraging unnecessary and sometimes harmful treatments.

Many chiropractors, whether knowingly or unknowingly, fall into the trap of misunderstanding or misapplying billing codes. Modifier 25 is often used incorrectly, leading to inflated charges. Modifier 59, which is meant to show that procedures are distinct, is frequently appended to procedure codes when no National Correct Coding Initiative (NCCI) edit exists to justify it.

And that’s just the tip of the iceberg.

??The Key Issue: Misuse of the Curative Zero Card

We recently had a deep dive into the chiropractic billing practices tied to the Curative Zero Card, a popular but misused tool. While it’s supposed to streamline billing, some providers have taken advantage of this tool by using it in ways that misrepresent the services actually provided.

Texas, for example, requires that providers submit itemized bills within 30 days of receiving payment (28 Tex. Admin. Code § 133.210). Yet, when these chiropractic schemes come into play, that rule is often ignored, leading to inflated charges, incorrect billing, and, ultimately, financial loss for both insurers and patients.

And don’t forget the legal implications. The Anti-Kickback Statute makes it clear that these arrangements—where services are bundled or billed incorrectly to increase reimbursement—are not just unethical but illegal.

??What Can Be Done?

So, how do we address this issue before it becomes an even bigger problem?

Here are some proactive steps every healthcare provider can take to stop chiropractic fraud in its tracks:

1. Update Member Benefit Plans: If you're in a position to set policies, ensure that your plans clearly address these billing practices. Require an Evaluation and Management (E/M) visit with a treatment plan for any "package deals." This ensures that the services being billed are medically necessary.
2. Monitor Credit Card Transactions: Instruct credit card companies to flag transactions associated with suspicious billing practices and to pend them until an itemized bill, compliant with NCCI guidelines, has been submitted. This extra layer of scrutiny can prevent fraudulent claims from slipping through the cracks.
3. Education is Key: Chiropractors, just like any other healthcare professionals, need to be properly educated on correct billing practices. Misunderstanding the proper use of modifiers like 25 and 59 leads to overcharges, which ultimately hurt patients and insurers alike.

It’s not just about the dollars—though, let’s be honest, billions of dollars are lost to healthcare fraud every year. It’s also about trust. The moment a healthcare provider engages in fraudulent practices, it erodes trust with both patients and insurers. This, in turn, creates a snowball effect, causing financial strain on everyone involved, while undermining the integrity of the healthcare system as a whole.

Chiropractors and other healthcare providers who engage in fraudulent billing may find themselves facing legal ramifications, damage to their reputation, and potential disbarment from insurance networks.

??How Advize Can Help

Our team works closely with providers, insurers, and other stakeholders to ensure compliance with the highest standards of care and billing practices. If you're concerned about chiropractic fraud or any other billing issues within your organization, contact us today for a comprehensive audit and learn how we can help protect your bottom line.

Together, we can stop fraud before it gets out of hand.