Palmetto GBA/Railroad Medicare reviews claims submitted for chiropractic services. Medicare covers manual manipulation of the spine to correct an acute subluxation. Subluxation means a partial dislocation of one or more bones in a patient’s spine.
For all claims submitted for payment, Medicare must be able to verify that the services are medically necessary and will give the patient a reasonable expectation of recovery or improvement.
Beginning in February 2013, Railroad Medicare expanded its Medical Review program to include a greater number of audits. This means Palmetto looks at claims to determine if the services met all the criteria for payment based on Medicare’s guidelines. Palmetto selected chiropractic services as an audit topic based on national data showing that claims of this type have been paid in error by Medicare.
Medicare can only pay for a chiropractor to treat acute problems and new injuries. In addition, the chiropractor must develop a treatment plan that has specific goals that are expected to be achieved and objective measures that will be used to evaluate how effective the treatment is. After each visit, the chiropractor must document the progress he or she is making toward meeting these goals, and they must have specific, measurable data. As an example, if the chiropractor’s goal is to increase a patient’s range of motion, he or she must say by how much and must document a baseline or a starting point so progress can be measured.
As part of the medical review process, Palmetto GBA sends a notice to chiropractors when they submit their claims and requests documentation to support the clinical necessity of each service. The chiropractor must respond with notes specific to each patient, for each claim randomly selected for review. If the chiropractor doesn’t keep notes (or the notes are vague or incomplete) then Medicare can’t pay for the service. If the chiropractor doesn’t respond to Railroad Medicare’s request for notes, Medicare can’t pay for the service. In these cases, the chiropractor is responsible for the charges and cannot bill the patient for the service.
If a patient’s treatment changes from addressing an injury to maintaining or preventing future deterioration of the spine, then Medicare can no longer pay for these chiropractic services. Continued treatments that don’t have achievable, clearly defined goals would be considered ‘maintenance therapy.’ This means, there is no expectation of improvement but the doctor plans to continue treatments that keep the patient at the same level of health. Medicare does not cover maintenance therapy. In this case, the patient is responsible for the bill.
If a patient thinks that Railroad Medicare should have paid for – or didn’t pay enough for – an item or service they received, he or she can file an appeal if their doctor has not already done so. Be sure to ask your doctor for any information related to the bill that might help your case. Appeal rights are listed on the back of the Medicare Summary Notice (MSN) that is sent from Railroad Medicare. All appeals must be requested within 120 days from the date you received your MSN, and they should be sent to:
Railroad Medicare – Palmetto GBA
P. O. Box 10066
Augusta, GA 30999
If you have questions about this review, you can call our Contact Center at 800-833-4455, Monday through Friday, from 8:30 a.m. to 7 p.m. ET. Medicare information can also be found on our website at www.PalmettoGBA.com/RR/Me. We also encourage you to sign up for email updates. To do so, visit our website and click ‘EMail Updates’ on the lower left-hand side of the Web page under ‘Stay Connected.’