ACA Zero Tolerance

Fraud Prevention Work Group September 28,

2006

Dr. George McClellandPast Chairman of the

Board

Commitment Number 1: Integrity 

ACA Policy on Fraud

“The ACA opposes any type of fraud within the

chiropractic profession….”

ACA Public Anti-Fraud Statement

“…doctors of chiropractic who use questionable practices

will find no safe harbor within

the borders of the ACA.”

National Insurance Crime Bureau

“As a provider organization, we believe we have a responsibility to do

everything we can to help stabilize or decrease health

care premiums for patients by policing our own ranks against

fraud.”

United States Attorney’s Office

“…ACA still considers this an important and serious issue and would be interested in meeting with officials from

the U.S. Attorney’s Office to develop more strategies to combat fraud in the health

care system.”

ACA Policy: CMT & E/Ms

“Some examples of when it is appropriate to bill a separate E/M code on the same day as a CMT code include a new patient visit, an established patient with a new condition, new injury, re-injury, aggravation, exacerbation, or a re-evaluation to determine if a change in treatment plan is necessary.”

ACA Policy: Testing and Measurement Codes

“These services are usually not billable over and above the E/M code…These codes may be billed along with CMT (CPT #98940-98943) as long as the required criteria have been met.”

Mobile Diagnostic Units

“We caution the chiropractic community when entering into a rental or lease agreement that is or could be perceived as placing financial gain over the best interests of the patient.”

Commitment Number 2: Raise the Bar

CCGPP’s Best Practices Evidence Based Care “means integrating individual clinical expertise with the best

available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that we individual clinicians acquire through clinical experience and clinical practice. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by external evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best external evidence, practice risks becoming rapidly out of date, to the detriment of patients.”

Sackett DL. “Evidence-Based Medicine” Semin Perinatol 1997; 21: 3-5.

CCGPP’s Best Practices

• Best Practices is a process: “It is not a specific practice per se but rather a level of agreement about research based knowledge and an integrative process of embedding this knowledge into the organization and delivery of healthcare…[it] can bridge the practice-research gap.”

Driever MJ. “Are evidence-based practice and best practice the same?” Wst J Nurs Res 2002; 24: 591 –7.

Guidelines vs Best Practice

RCT

Guidelines

RCT

Best Practice

Cohort

Case Series

“Recommendations”Treatment options: A = 80%, B = 25%

C = 5%, D = 0%

Clinical judgement & experience

CCGPP Risk StratificationCategory Factor

Personal Age (older) 23;24 31

  Gender (female) 23;24 25

  Severity of symptoms23;24 25

  Leg pain > back pain 25;26

  Increased spine flexibility32

  Reduced muscle endurance 32;33

  Prior recent injury (< 6 months) including surgery23;24;29;34 25;35;36 37 26;38

  Prior surgery 37 38

  Asymmetric atrophy of multifidus up to 5 years later 39 40

  Abnormal joint motion with or without abnormal emg function of medial spine extensors 41  Poor body mechanics 34.

  Falling as mechanism of prior injury29 42

Biomechanical Prolonged static posture > 20 degrees (odds ratio 5.9) 43

  Poor spinal motor control 44

  Vehicle operation > 2 hours per day 45

  Sustained (frequent / continuous) trunk load > 20 lbs45

  Materials handling (Static work postures, and repetitive exertion) 29.

Psychosocial Condition chronicity  Employment history (<5 years same employer) 23;24 25

  Employment satisfaction 27

  Lower wage employment 25

  Family / relationship stress27

  Attorney retention  Expectations of recovery

Best Practices CCC Cont’d… • From the 60 day public comment period all

comments will be gathered and reviewed by the teams.

• Amendments, as appropriate, will be added.• Responses to comments, whether accepted

or rejected, will be published with rationale, in the final version.

• The final document is scheduled to be published in 2007.

PO Box 2542 Lexington, SC 29071 PO Box 2542 Lexington, SC 29071

Phone 803.808.0640 Fax 803.356.6826Phone 803.808.0640 Fax 803.356.6826

Email: Email: ccgpp@sc.rr.comccgpp@sc.rr.com

www.ccgpp.orgwww.ccgpp.org

““Council on Chiropractic Guidelines and Practice Parameters” and the “Chiropractic Clinical Compass” copyrighted to Council on Chiropractic Guidelines and Practice Parameters” and the “Chiropractic Clinical Compass” copyrighted to CCGPP 2006 CCGPP 2006

Over-Utilization of X-Rays

Patient Revolving Door

Commitment Number 3: Meaningful

Outreach 

Commitment Number 4: Setting the Skewed Stuff

Straight 

Appropriate Care

Deception

ACA’s Pledge

National BCBS Thanks ACA

“BCBSA commends the ACA for adopting this clear and comprehensive statement

that will go a long way toward educating doctors of

chiropractic about the serious ethical, quality, and legal

concerns that may arise from relationships with mobile

diagnostic service providers.”

Closing