USA TODAY, April 29, 2014
By Jayne O’Donnell, Meghan Hoyer and Yamiche Alcindor, USA TODAY
More than 36,000 chiropractors were paid nearly $500 million by the federal government in 2012, making chiropractors one of the largest groups of Medicare providers. And one chiropractor in Brooklyn topped the list, receiving more than $1 million that year alone.
Alexander Khavash, who works in Brooklyn out of a rented office, received nearly twice the Medicare payments than any other practitioner in his field, according to data released this month by the Department of Health and Human Services.
Overall, chiropractors provided 21 million taxpayer-funded treatments for 2.5 million beneficiaries, the Medicare data show. But just 600 chiropractors, including Khavash, accounted for more than 10% of the Medicare payments.
Khavash was the only chiropractor in the top 1% of all individual practitioners paid by Medicare in 2012. According to the Medicare data, he performed more than 42,000 procedures on more than 2,500 patients.
Early last week, Khavash denied doing that many procedures and refused to comment about the $1 million. Then, in an interview at his office Saturday, he said he had eight chiropractors working for him and using his identification number in 2012. He declined to provide the chiropractors’ names, but said Medicare is aware of them. He said they work at different locations than he did in 2012.
He now works out of a Brooklyn physical therapy practice and says he has four chiropractors working for him out of other locations. “I go by the book,” Khavash said. “I earned my license. It took me a long time to earn it. I’m not about to mess it up by playing games with Medicare, or any insurance for that matter.”
Khavash says he’s been through several Medicare audits, including in 2012. He is not on the HHS list of those providers excluded from receiving federal healthcare funding.
“Medicare is fine with everything that I am doing because I have been doing it for a while and I do it by the book,” Khavash says. “If Medicare says I can’t do something. I don’t do it.”
Experts say Khavash’s payment records raise questions because they are far out of line with his industry’s average. Medicare paid the typical chiropractor only about $9,322 in 2012, the data show. In general, Medicare payments made up about 13% of a chiropractor’s income in 2013, according to a report out last year by the trade magazine Chiropractic Economics.
Chiropractors say it’s money well spent, as spinal adjustments can prevent the need for far-costlier orthopedic surgery or use of risky pain medications. But others see potential for fraud and abuse.
When told of the $1 million earned by a single chiropractor, Meghan Dugan-Haas, director of federal and regulatory affairs for the American Chiropractic Association, said it “does sound suspicious.”
“He’s not an ACA member,” she said. “I wish he would become one so we can find out what’s going on.”
The trade group, the largest in the field, gives members access to proper Medicare billing and informational resources that “promote the highest standards of ethics in the profession,” she said.
The Centers for Medicare and Medicaid Services does not comment on individual practitioners, but said in a statement that it has “cracked down on tens of thousands of health care providers suspected of Medicare fraud.”
Khavash’s reimbursements underscore some of the challenges in interpreting the data, which link payments to doctors’ federal healthcare identifier numbers. Two physicians publicized this month for receiving about $10 million from Medicare said it was because others used their numbers to bill for drugs and lab tests.
Still, Khavash and the other top chiropractors earn far more from Medicare than most. The next biggest chiropractic recipient of Medicare dollars brought in more than $523,000 and the rest of the 10 biggest earners each made more than $200,000. Nine out of the 10 were in or near New York City; half were in Brooklyn.
HHS regularly excludes some doctors from receiving federal healthcare funding, including for Medicare, and maintains a database of their names. Chiropractors were twice as likely as other specialties to have felony-level fraud as the reason.
The American Chiropractic Association says it takes an average of 15 minutes for its members to perform spinal manipulations, the only procedures chiropractors can bill to Medicare.
Efficient practices with large support staffs to handle recordkeeping can handle 100 or more patients a day. Tony Nicholas, a Griffin, Ga., chiropractor and former head of the ethics committee for the state’s chiropractic association, used to treat that many in a day.
Still, he says a chiropractor who does as much Medicare business as Khavash — or even those earning $300,000 from Medicare — raises questions. The average Medicare payment per adjustment is less than $25.
“How’s he doing it? That’s what’s going through my mind,” Nicholas said.
Khavash would have had to be treating a patient every three minutes for 10 hours a day, five days a week to perform 42,000 treatments in 2012.
CMS doesn’t prohibit providers from using others’ identification numbers but discourages it, the agency told reporters after the data’s release. Nicholas said it is uncommon and inadvisable in case of malpractice claims.
If Khavash did have eight chiropractors working for him and using his number, they averaged more than $110,000 in payments — higher than 99.8% of chiropractors in the Medicare data.
There have been several recent cases of Medicare fraud involving chiropractors, including the October indictment of a Wichita chiropractor for a $1.3 billion fraud scheme that included submission of claims to Medicare and other benefit providers for services that were medically unnecessary or never performed.
A trial date could be set as early as Friday in an October 2012 case involving four New York chiropractors who were indicted for allegedly using assisted living facility residents’ identities to fraudulently bill Medicare for more than $6 million.
Los Angeles health care lawyer Tracy Green has represented many chiropractors and says the specialty has “a fair amount of regulatory problems and fraud.” Part of the problem is that “they are the ones doing the care” frequently in auto insurance fraud cases and some run pain management clinics, a field that’s closely watched given all the pain medication abuse and fraud.
CMS says thanks to the Affordable Care Act it has new tools to find fraud and abuse in the Medicare program, including new enrollment screening techniques that keep high-risk providers from getting into the system, and a new analytic system that detects and stops fraudulent billing before money is paid. The government recovered a record $4.3 billion in taxpayer funds last year on behalf of federal health programs.
Since 1999, the inspector general has stopped 152 chiropractors or chiropractic offices from receiving federal health care funds — including Medicare payments — because of felony convictions relating to health care fraud. A doctor convicted of fraud is excluded from federal programs for at least five years. An additional half dozen were excluded for at least three years for misdemeanor health care fraud convictions, and 74 others for “program-related” convictions related to their delivery of services to patients.
During the same time period, 240 chiropractors and 145 chiropractic offices were prohibited from receiving federal funds because doctors either voluntarily surrendered their license or had their license revoked or suspended. As with the fraud cases, doctors and offices could seek reinstatement into the Medicare program at the end of their suspension. The way the government keeps the data makes it difficult to assess how many doctors who have been excluded from federal programs have later been reinstated.
Chiropractor Robert Hayden, a spokesman for the chiropractic association, says data sets like the new Medicare numbers will always have extreme examples or “two tails of a bell curve.”
“There’s a tendency to look askance at those outliers,” says Hayden, who is based in Griffin, Ga. “There’s frequently more than just the data there … and more than meets the eye.”