Compliance Risks of Integrative Health
Integrative Health: A New Frontier
The Mayo Clinic describes Integrative Health as “services for your physical, emotional, spiritual and mental health and well-being. Integrative medicine is an approach to healthcare that includes practices not traditionally part of conventional medicine, such as herbs, acupuncture, massage, yoga, and meditation.”
Compliance Risks For Organizations Offering an Integrative Approach These non-traditional approaches are gaining a lot of acceptance, and some of these treatments help many patients. But like any more recently accepted treatment type, the increase in the volume of these services can sometimes be accompanied by compliance risk. Of course, it is not necessarily the nature of the treatment that is a compliance risk, but rather the inappropriate billing or performing medically unnecessary services that brings the compliance risk.
For example, inappropriate billing of acupuncture services resulted in a Mississippi family physician settling false claims act allegations for approximately $375,000. The allegations included the billing for non-reimbursable acupuncture devices (P-Stim) that were not surgically implanted despite using billing codes indicating that they were. In other words, it was alleged that because Medicare didn’t cover acupuncture, the physician reported codes he knew would be reimbursed. Those codes did not accurately reflect the true acupuncture services and devices he provided. According to the court documents, P-Stim is an electro-acupuncture device that, according to the manufacturer’s instructions, is affixed behind a patient’s ear using an adhesive. Needles are inserted into the patient’s ear and attached using another adhesive. Once activated, the device then provides intermittent stimulation by electrical pulses. It is a single-use, battery-powered device designed to be worn for approximately four days until its battery runs out, at which time the device is thrown away. Medicare does not reimburse for such acupuncture devices, nor did the physician perform surgical implantation of these devices as he billed to Medicare. Other brand names include Stivax, NeuroStim, ANSiStim, E-Pulse, and NSS-2 Bridge.
The U.S. Attorney involved in prosecuting the case stated,
“This office will hold accountable those providers who are improperly paid for non-reimbursable acupuncture under the guise of surgically implanted neurostimulators.”
In a different case, massage services were alleged to have been involved in Medicare fraud. In this case, Medicare was billed for physical therapy, a covered benefit, but the actual services provided were massage, which was not covered by Medicare. Because Medicare was billed for covered physical therapy services, they reimbursed the organization. It was until later that it was discovered the service provided was massage.
A third case involved allegations of a doctor abusing chelation therapy to treat “excess body burden of heavy metals.” The doctor, in this case, practiced personal integrative medicine and advertised on his website that chelation could treat numerous conditions and be used as an anti-aging treatment to stimulate bone growth, lower blood pressure and prevent cancer. Chelationtherapy has its place in removing toxic metals from the body. When metals like lead, mercury, iron, and arsenic build up in your body, they can be toxic. Chelation therapy is a treatment that uses medicine to remove these metals so they don't make you sick.
The government alleged that the doctor falsely diagnosed patients suffering from heavy metal poisoning (particularly lead poisoning) and then billed Medicare for their treatment. Additionally, they alleged the physician undertook chelation therapy and administered the chelation drug edetate calcium disodium (EDTA) to Medicare beneficiaries who were not suffering from lead poisoning. Chelation therapy is a rarely used treatment generally only for individuals suffering from lead poisoning and other forms of heavy metal poisoning. EDTA, one of the drugs used in chelation therapy, is indicated only for lead poisoning and lead encephalopathy. The government contends these chelation treatments were contrary to the standard of care and medically unnecessary.
The government claimed the physician submitted some 4,500 claims and collected about $1.5 million for what the lawsuit calls medically unnecessary chelation therapy.
Specificity Matters When Billing For Services
Even though some integrative health treatments can be beneficial to patients, if an insurance program like Medicare does not cover the service, the payor should be not billed for different services that are likely to be covered. In other words, if you’re going to provide integrative services, you need to call a spade a spade, even if it means insurance will not cover the services. The patient may be personally responsible for reimbursing the provider.
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