April 21, 2014 International Chiropractors Association

US Department of Health & Human Services Report on Chiropractic Misses Key Points on Chiropractic Cost Effectiveness

The report entitled Chiropractic Services in the Medicare Program: Payment Vulnerability Analysis , issued June 21, 2005 by the Office of the Inspector General (OIG) of the US Department of Health and Human Services is not the first document produced by that office that presented a negative perspective on the chiropractic portion of the massive Medicare program. The essence of the findings presented in this 38 page report is that the majority of chiropractors are billing Medicare for “medically” unnecessary treatment. According to the report itself, the objective of the study was “to determine the underlying causes of, and potential ways to reduce, vulnerabilities associated with Medicare payments for chiropractic services”. The methodology, again from the report itself, was presented as follows: “to gain a deeper understanding of the underlying causes of these vulnerabilities (maintenance care) and ways to reduce them, we selected a simple random sample of 400 Medicare services (total allowed amount = $12,638.38) submitted by chiropractors and allowed in 2001”.

Their key conclusions were:

  • Maintenance services were the most common type of non-covered chiropractic service that Medicare paid for in 2001.
  • Supporting documentation for chiropractic services rarely met all Medicare Carriers Manual requirements.
  • Carrier controls to prevent over utilization are inconsistent

ICA's Medicare Committee undertook a detailed analysis of this report and the context in which it was developed and issued and came to some very clear conclusions of its own regarding the OIG's motives and what the chiropractic profession's reactions should include. “The clear goal of the OIG and the historically anti-chiropractic bureaucrats that permeate HHS is to provide a rationale for a hard cap of chiropractic services, somewhere around 12 visits per year”, said ICA Medicare Committee Chair Dr. Michael J. Hulsebus “This type of thinking reveals a prejudice that can only be described as ridiculous public policy, since if you cut off Medicare beneficiaries' access to needed chiropractic care with a hard cap, especially one based on an arbitrary definition of what constitutes “:maintenance care”, all you are dong is driving them to the care of other providers, particularly medical specialists, the costs of which are massively higher than the cost of the care denied,” Dr. Hulsebus stated.

As a matter of policy, unlike some other chiropractic organizations, ICA strongly opposes any arbitrary and finite limitation on chiropractic services in any public health program, and will fight any legislative or regulatory initiative that proposes such a limitation. ICA 's Legislative Committee has already met to mobilize the profession-wide as well as the grass roots resources that will likely needed to be applied to defeat Medicate limits legislation in the US Congress in the near future.

ICA 's Medicare Committee also took issue with Medicare's definition of what constitutes maintenance care, and the emphasis on symptoms and complaints. “The definition of maintenance care used by the OIG in this report was developed by Medicare to meet their economic containment goals for chiropractic utilization, and not from a responsible examination of the legitimate chiropractic needs of the Medicare population,” Dr. Hulsebus said. “It is clearly an arbitrary definition, which needs to be changed.”

At the same time, ICA 's Medicare Committee noted the importance of closely following and clearly understanding the Medicare program's documentation criteria. “The focus on the “Carriers Manual” in the OIG report is an important reminder for doctors of chiropractic nationwide to obtain current copies of this key document and study it carefully, to fully understand and be in the best possible position to comply with the program's requirements,” said ICA Medicare Committee Vice Chairman Dr. Gary Street. ICA has conducted dozens of Medicare Seminars around the United States featuring Dr. Street and his research and analysis on the Medicare program and its compliance requirements, in an effort to better educate DCs on this vital program. “Knowing what is in the Carriers Manual will make all the difference in the world, and will help you better serve your patients, as well as protect your practice from Medicare claims of over utilization,” Dr. Street said.

ICA encourages all DCs involved in Medicare to obtain and carefully read the Carriers Manual , paying special attention to Section 2251.2, Documentation of Subluxation and that section reads in part, “A subluxation may be documented by an x-ray or by physical examination, as described below.


  1. Demonstrated by X-Ray : An x-ray may be used to document subluxation. The x-ray must have been taken at a time reasonably proximate to the initiation of a course of treatment. Unless more specific x-ray evidence is warranted, an x-ray is considered reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of a course of chiropractic treatment.
  2. Demonstration by Physical Examination : Evaluation of musculoskeletal/nervous system to identify:
    1. Pain/tenderness evaluated in terms of location, quality, and intensity;
    2. Asymmetry/misalignment identified on a sectional or segmental level;
    3. Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility); and
    4. Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament.
  • Symptoms causing patient to seek treatment;
  • Family history if relevant;
  • Past health history (general health, prior illness, injuries, or hospitalizations, medications, surgical history);
  • Mechanism of trauma;
  • Quality and character of symptoms/problems;
  • Onset, duration, intensity, frequency, location and radiation of symptoms;
  • Aggravating or relieving factors; and
  • Prior interventions, treatments, medications, secondary complicates”.

Contact your Medicare provider representative and request in writing copies of all current portions of the Carriers Manual that pertain to chiropractic. Read it, understand it and follow it. Also, understand that the work of documentation and record keeping must be done and done on an accurate and timely basis.

ICA has also sought ways and means to assist DCs in the realm of documentation, and this was one primary reason ICA's Board of Directors recently endorsed the Myo-Logic muscle testing and documentation system. “This technology is the kind of measurement-based documentation mechanism that all insurance carriers, both public and private, will be obliged to recognize,” said ICA President Dr. John Maltby. “I also want to thank and commend ICA 's Medicare Committee for their exceptional effort on behalf of ICA members on this key matter. I also want to say publicly that they have the full support of the ICA Board of Directors and my deepest respect and appreciation as ICA President, as they undertake this important task of defending not just the chiropractic profession from this latest implied Medicare threat, but of defending millions of senior citizens who both need and want our care.”

The political and prejudicial motives of the OIG and those to whom they are responding with reports such as this latest one should be lost on no one, especially when the report itself acknowledges that the chiropractic share of the Medicare program is all but microscopic in size, and even if all of the changes they indicate they want are made, the impact on the overall program will be invisible in terms of the bottom line. It will, however, be devastating to chiropractors and patients, and set a disastrous precedent for all similar programs, not just in the United States , but to other nations who look to Medicare as a model. This, ICA is determined to prevent.

OIG Report, June 2005