The Importance of Accurate Billing Practices

by Ray Foxworth, D.C., FICC • 

President & Founder, ChiroHealthUSA • 

In recent news, U.S. Attorney Jacqueline C. Romero announced two significant civil settlements totaling nearly $2 million. These settlements are part of a broader national investigation into improper billing practices using the RST Sanexas neoGEN-Series device (“Sanexas”).

Understanding the Case: Sanexas and Billing Discrepancies

The Sanexas device, an electric stimulation tool marketed by RST Sanexas, Inc., is designed to treat various forms of pain and medical conditions, including diabetic neuropathy. Treatment typically involves outpatient sessions twice weekly over twelve weeks, often coupled with vitamin injections.

Two chiropractic clinics, Active Integrated Medical Centers, PC, and Nova Integrated Health, PC, were recently implicated in improperly billing the Sanexas device and related treatments. The settlements are a stark reminder of the repercussions of incorrect billing practices:

• Active Integrated Medical Centers: Co-owned by Dr. Joseph M. Childs and Dr. Charles H. Durr, this clinic submitted over 67,000 claims to Medicare between February 2020 and April 2022, resulting in a $1.9 million settlement. However, the U.S. filed a complaint to enforce the agreement due to non-compliance with the settlement terms.
• Nova Integrated Health: Owned by Dr. Taylor Vanden Wynboom, this clinic submitted approximately 33,000 claims between March 2019 and November 2020, leading to a $52,000 settlement. (DOJ, 2024)

Key Issues Highlighted

The settlements revealed several critical issues:

1. Non-Covered Treatments: According to Medicare’s National Coverage Determination 160.7.1 and various Local Coverage Determinations (LCDs), electrical nerve stimulation treatments, such as Sanexas, are excluded from coverage when performed in specific settings or manners. Furthermore, combining these treatments with vitamin injections, as practiced by the implicated clinics, was not FDA-approved and deemed medically unnecessary.
2. Improper Use of Billing Codes: The billing codes used by the clinics for Sanexas treatments and associated vitamin injections, were found to be inappropriate and medically unnecessary.
3. Unnecessary and Painful Testing: The clinics also conducted extensive testing, such as epidermal nerve fiber density (ENFD) and TM Flow testing, purportedly to justify the need for Sanexas treatments. These tests, however, were not FDA-cleared or covered by Medicare in the manner conducted.

Lessons for Chiropractors

1. Due Diligence in Billing: Chiropractors must thoroughly understand and comply with Medicare coverage determinations. Blind reliance on device manufacturers and distributors can lead to significant legal and financial repercussions.
2. Verify Treatment Approvals: Ensure Medicare or other insurance policies cover new treatment devices or methods. This includes verifying the appropriateness of combining treatments, such as electrical stimulation with vitamin injections.
3. Proper Use of Billing Codes: Accurate and appropriate use of billing codes is essential. Codes must reflect the actual services provided and comply with coverage requirements, including necessary patient supervision and direct contact during treatments.
4. Avoid Unnecessary Testing: Conduct only medically necessary tests covered by insurance and within the scope of your practice. Unnecessary tests not only burden patients but also risk non-compliance with insurance guidelines.

The recent settlements are a critical reminder of the importance of accurate billing and thorough verification of treatment practices. Chiropractors must remain vigilant and informed about regulatory requirements to avoid legal entanglements and ensure the sustainability of their practices. By adhering to these guidelines, chiropractors can provide quality care without compromising their professional integrity or financial stability. Not sure if you are billing and coding correctly in your practice, reach out to ChiroArmor for a free gap analysis.