Chiropractors received an estimated $285 million in improper Medicare payments in 2001, according to the inspector general's office of the Department of Health and Human Services. That amounts two of every three dollars paid to chiropractors by the federal health insurance program.

Some people consider periodic manipulations of the spine valuable for maintaining mobility and reducing pain. (See some details under "What Really Works?" Page F1.) The inspector general's analysis found that most of the ineligible payments -- $186 million in all -- went for such maintenance treatments. But Medicare is supposed to cover chiropractic care only when there is a reasonable chance of correcting a problem or improving the patient's ability to function.

Chiropractor Elliott Eisenberg of Richmond said he often sees people whose "spines are so degraded that they'll never get better." While treating them can ease their pain, he said, "I can't charge Medicare for that."

Mark McClellan, administrator of the Centers for Medicare and Medicaid Services, noted in a response to the analysis that previous studies have cited improper payments for maintenance care. He said his agency has taken steps to further educate providers and to target those who do not follow the rules.

The American Chiropractic Association challenged the report, saying in a statement that the findings "do not represent a concerted effort by doctors of chiropractic to overbill the government. . . . The flawed payments "reflect a universal problem in physician documentation" of claims, the association said. . . . "[I]t is simply wrong to conclude . . . that chiropractic care typically rendered to Medicare beneficiaries is not necessary or appropriate."

Meanwhile, Medicare is actually encouraging wider use of chiropractic care. In a demonstration project covering central Virginia and other parts of the country, chiropractors can now bill the insurance program for services that are ordinarily ineligible.

The purpose of the test, according to a statement by McClellan, is "to evaluate whether expanding coverage of chiropractic services reduces overall Medicare expenditures for neuromuskuloskeletal conditions."

Richmond chiropractor Nelson Gregory said many of his Medicare patients now have their physical therapy bills covered. "They're definitely getting more services and better coordination of those services" as a result of his decision to enroll in the pilot project, he said.

Eisenberg is not participating in the study. "Chiropractic used to have people paying cash for a valued service," he said, but many of his colleagues have become dependent on insurance plans that cover only a limited scope of treatment. "I feel it's a slippery slope" to cooperate in the Medicare project, he said.

-- Tom Graham

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