In the late 1990’s, the government, via well publicized news releases, requested that “ALL” health care providers implement health care compliance programs as a means to self-police themselves to ensure compliance with health care laws and rules, as well as to facilitate detection and correction of identified misconduct. This request was made in conjunction with the governments increased focus on combating health care fraud, that was greatly enhanced by the passage of the Health Insurance Portability & Accountability Act of 1996 (HIPAA).


Unfortunately, when most health care providers hear “HIPAA” they think of patient confidentiality and record security, but not the most significant aspect of this law - the expanded ability of the federal government to combat health care fraud and abuse, including:


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For years significant resources have reportedly been directed towards combating health care fraud by insurers, regulators, law enforcers and legislators. Yet, despite these reported efforts, it would appear, based on the annual estimates, the problem continues to grow and flourish. Could this indicate that health care fraud is at epidemic proportions and can’t be stopped as our health care system is infested with health care providers who will stop at nothing to make a buck? I think not.


My experience, over two decades of working with insurers, law enforcers, regulators and health care providers, suggests that most health care providers are honest, ethical and strive to do the right thing! Additionally, my experience has provided me with the opportunity to see the fraud problem from both sides, that of enforcement and the provider. When viewed from both perspectives, it is readily apparent that our health care fraud problem is caused by a number of factors, including:


1. Inadequate education for health care providers relative to coding and payer standards.


2. Deviant providers.


3. Inadequate training for claims handlers and claims investigators on coding and provider standards.


4. Inept claims handling and claims investigations by insurers prior to paying claims.


5. Lack of communication from insurer to provider on what is required.


6. Paucity of reliable training for law enforcers regarding the investigation of health care fraud – from identification to prosecution.


7. Tag-a-long investigators looking for organizational stats resulting in the inefficient use of law enforcement resources.


8. Lack of interest or commitment by prosecutors – big cases big problems, little cases little problems.


9. Lack of accountability for all segments of the health care delivery system – provider, payer, regulator and enforcer.


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Is health care fraud more prevalent in claims submitted by chiropractors than those submitted by members of other health care disciplines? When looking at the various news-sources, chiropractors are not found to make up either the lion-share of health care fraud charges or convictions reported.


Unfortunately, instances of fraud & abuse are present in ALL health care disciplines - Chiropractic, Medicine, Physical Therapy, etc. There is no single discipline that can lay claim to a proportionately higher rate of fraudulent conduct than any other health care discipline. However, despite this fact, there is an ongoing feeding-frenzy of insurers investigating chiropractic claims. These investigations go beyond simply evaluating either the merits or medical necessity of claims to determine if they should be paid.


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1. Not knowing what acronyms CPT and ICD-9-CM stand for could be a possible indicator of inappropriate billing practices by health care providers and claims handling by third party payors.


TRUE: Those having a strong knowledge base and understanding of these coding systems will know what the acronyms mean!


2. All health care providers billing third party payers are under investigation.


TRUE: Payers will conduct some form of evaluation or investigation to determine whether to pay a health care claim or not. The key here for providers is what happens as a result of the investigations - claims paid, claims referred for further investigation, claims denied, etc.


3. Health care providers promising "free" consultations as part of marketing efforts to attract new patients should not bill new patient exams on those receiving free consultations.


TRUE: New patient exams require that the provider meet or exceed the key components of an exam - History, Physical Exam and Medical Decision Making. The promised free consultation will include gaining historical data from the patient on their current and past health conditions, and, as such this data collection would be part of the History component of a new patient exam.


4. Health care providers not treating Medicare beneficiaries or billing Medicare need not be concerned about learning Medicare laws and rules.


FALSE: Today's health care provider will find that many insurers indicate that they follow Medicare guidelines when making their claims reimbursement decisions.


5. One of the most significant aspects of "HIPAA" were provisions it provided to enhance the investigation and prosecution of health care fraud.


TRUE: This act provided for new federal laws to prosecute health care fraud, expanded the ability of prosecutors to access information, financial rewards to investigators for successful prosecutions, etc.

An attorney writing in a chiropractic periodical reported hearing a scary story from a chiropractor that goes: Chiropractor hired a consultant to conduct an audit of his practice, and on completion of the audit the consultant demanded a low five-figure payment from the chiropractor to ensure compliance and implementation of recommendations. The chiropractor declined to pay for the extended services and several months later the chiropractor was contacted by the government who were focusing on the same problems highlighted by the consultant.


The problem with this story is that no substance is provided to allow readers to evaluate the validity of the events claimed. Another BIG PROBLEM is that the attorney fails to mention that frequently providers may seek out audit and compliance services because they already suspect they are being investigated! However, in reading the attorney’s entire article its purpose is clear – health care providers should exercise appropriate due care prior to, during and after their decision to audit their health care practices!


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