CMS to Draft Rule Requiring Prior Authorization for Chiropractors

Look for a proposed rule later this year that could make it harder for some chiropractors to submit Medicare claims. The Centers for Medicare & Medical Services is looking to require chiropractors with high rates of claim denials to obtain prior authorization before treating a patient.

Chiropractors impacted will have to submit a request for coverage before they can provide that service.

“Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), this proposed rule would establish a prior authorization process as a condition of Medicare payment for manual manipulation services provided by certain chiropractors whose pattern of billing is aberrant compared to their peers and whose services denial percentage is in the 85th percentile or greater, taking into consideration the extent that service denials are overturned on appeal,” according to information published in the Unified agenda, a semiannual compilation of information about regulations under development by federal agencies

This should come as no surprise, given that under federal law, (MACRA), CMS was supposed to impose prior authorization for chiropractic services on or after Jan. 1, 2017, but to date had not.

The move is seen as a way to reduce fraud. In February, the Health and Human Services Office of Inspector General (OIG) issued an OIG Portfolio entitled, “Medicare Needs Better Controls to Prevent Fraud, Waste, and Abuse Related to Chiropractic Services.”

In it the OIG notes several highlights:

  • Medicare continued to make hundreds of millions in improper payments for chiropractic services;
  • CMS’s controls have not fully prevented improper payments;
  • Chiropractic fraud, waste and abuse is a concern;
  • Establishing a medical review threshold for chiropractic services cold save millions by reducing payments for medically unnecessary services without compromising beneficiary access to reasonable and necessary services.

The OIG noted that CMS’s Comprehensive Error Rate Testing program, which measures improper Medicare fee-for-service payments each year, identified chiropractic services as having the highest improper payment rate among Part B services from 2010 to 2015. Furthermore, the OIG noted that since 2005, the OIG has conducted numerous evaluations and audits of chiropractic services and identified hundreds of millions of dollars in overpayments.

The majority of those services identified as being improper were for those that Medicare considers medically unnecessary, including maintenance therapy.

In fiscal year 2016, Medicare spent approximately $540 million on chiropractic services. Look for the proposed rule sometime in December.

The Health Law Offices of Anthony C. Vitale has extensive experience representing clients in audits and overpayments and we can represent your interests through all of the stages of the overpayment appeals process in an effort to achieve the most successful results. Contact us for additional information at 305-358-4500 or send us an email to and let’s discuss how we might be able to assist you.

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