By Dr. Ray Foxworth, DC, FICC
Picture a Tuesday afternoon in a chiropractic office.
The doctor is adjusting patients. The CAs are juggling phones, checkouts, and a waiting room that somehow filled up all at once. In the back office, someone opens an envelope from Medicare.
Records request.
Nobody saw it coming.
The first reaction is usually, “Why us?”
That question is worth asking, because the way practices get noticed is changing.
For years, many chiropractors pictured an audit beginning with someone sitting at a desk and pulling a handful of claims. Today, computers can first look at enormous amounts of claims data. They can identify unusual billing patterns, compare providers with their peers, spot statistical outliers, and help determine where a closer look may be warranted.
CMS says its Fraud Prevention System uses machine learning to monitor and analyze Medicare fee-for-service claims before payment. Its program-integrity contractors also have access to claims histories, provider profiles, peer comparisons, average billing reports, and other analytical tools.
That does not mean artificial intelligence is sitting somewhere reading every chiropractic SOAP note and deciding who gets audited.
But it does mean your billing tells a story long before anyone asks for your documentation.
What story is yours telling?
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Medicare Is Looking for Patterns
CMS’s Medicare Program Integrity Manual specifically directs contractors to use data analysis to identify potential claim-payment errors and potential fraud. That analysis can include finding statistical outliers in billing patterns or detecting patterns across groups of claims that may suggest improper billing or payment.
Think about what that means in a chiropractic practice.
One claim may not look unusual.
A hundred claims may reveal a pattern.
A thousand claims can reveal one very clearly.
If virtually every Medicare patient receives the same frequency of care, the same code combination, or follows an unusually similar utilization pattern, the claims data may show that consistency before anyone ever sees the patient’s chart.
That does not automatically mean the care was improper.
An outlier is not the same thing as fraud.
But being different from your peers can cause someone to ask why. Once that question is asked, your documentation may need to provide the answer.
The Technology Is Already Here
This is not something coming five years from now.
CMS describes its Data Analytics and Systems Group as its primary focal point for data analytics and systems used to prevent fraud, waste, and abuse. CMS says these efforts include data mining, behavioral analysis, network analysis, predictive analytics, and machine-learning analysis.
Its Fraud Prevention System monitors Medicare fee-for-service claims using machine learning, while Unified Program Integrity Contractors (UPICs) perform fraud, waste, and abuse detection and prevention activities.
In June 2026, the Department of Justice announced its National Health Care Fraud Takedown, which included charges against 455 defendants and more than $6.5 billion in alleged false claims. DOJ specifically pointed to the use of cutting-edge data analytics in identifying targets.
Those were fraud cases involving conduct far beyond the normal mistakes we worry about in an ordinary chiropractic office, and we should not confuse criminal fraud with an innocent coding or documentation error.
But the enforcement strategy tells us something important:
The government has gotten very good at looking for patterns.
CMS also reported $41.9 billion in Medicare program-integrity savings for fiscal year 2025, a 59% increase from the previous year. According to CMS, 68% of those savings resulted from cost-avoidance activities such as revocations and automated claim denials rather than recovering money after it had already been paid.
The direction is pretty clear.
The goal is increasingly to identify questionable activity earlier.
What Would Stand Out About Your Practice?
This is where I want us to bring this conversation back home to chiropractic.
If Medicare compared your claims with those of other chiropractors in your region, what would stand out?
Do nearly all your patients receive the same number of visits?
Does one chiropractor in your practice consistently bill very differently from the others?
Are your treatment patterns driven by the patient’s documented condition, or does everybody seem to travel down essentially the same road?
Does your documentation change as the patient improves, worsens, or plateaus?
Could you explain an unusual utilization pattern if someone asked?
These are not questions about making your practice look more “normal.” Please do not misunderstand me.
We should never change appropriate patient care simply to match somebody else’s statistics.
The question is whether the care we provide is medically necessary, properly documented, correctly coded, and defensible.
If you are an outlier for a legitimate reason, your records should help tell that story.
Cloned Documentation Creates Its Own Problem
Billing data is only part of the picture.
OIG’s fraud, waste, and abuse education materials specifically identify documentation issues and abnormal billing patterns indicating overutilization as potential red flags.
Most chiropractors understand that copying yesterday’s note into today’s record can create problems. The bigger danger comes when templates make every patient start sounding remarkably alike.
We have all seen notes where the date changes but very little else does.
Templates are not the enemy. They can make a busy chiropractic practice more efficient and help us capture information consistently.
But a template should help us document the patient in front of us. It should not turn ten different patients into ten copies of the same patient.
Your record should reflect what happened that day.
What changed?
What did you find?
Why was today’s service necessary?
How is the patient responding?
Does the treatment plan still make sense based on the patient’s current condition?
If a records request follows an unusual billing pattern, those details become mighty important.
Audit Yourself Before the Computer Does
You do not need sophisticated artificial intelligence to begin looking at your own patterns.
Start with the reports already available inside your billing system.
Look at your Medicare utilization.
Review your most frequently billed codes.
Compare doctors within the practice.
Look at treatment frequency and duration.
Review patients who have unusually long episodes of care.
Then pull a sample of the records behind those claims.
Does the documentation support what was billed?
Can you follow the patient’s progress through the record?
Would another chiropractor reviewing the file understand why the care was provided?
Are your notes individualized?
Do your claims and your records tell the same story?
I have said for years that one of the worst times to discover your compliance problem is after somebody else discovers it first.
Technology has simply made that lesson more important.
Do Not Practice Scared. Practice Prepared.
Whenever artificial intelligence enters a conversation, it is easy to jump from reasonable concern to science fiction.
That is not what this is about.
This is about recognizing that Medicare’s program-integrity tools are becoming more sophisticated. CMS and its contractors can analyze billing at a scale no human auditor sitting with a stack of paper charts ever could.
That should not frighten a chiropractor who is providing appropriate care and documenting it well.
It should motivate us to look at our own data.
At ChiroHealthUSA, we have always encouraged doctors to make compliance part of the practice rather than something pulled off a shelf when an audit letter arrives. Train your team. Review your billing. Check your documentation. Know your numbers. When something looks unusual, find out why.
Your claims are already creating a picture of your practice.
The question is whether you have looked at that picture yourself.
Because the next auditor may not begin with your SOAP note.
They may begin with your pattern.
References:
- Centers for Medicare & Medicaid Services. Data Analytics & Systems Group Business Systems: Fraud Prevention System. Updated March 2026.
https://www.cms.gov/data-research/computer-data-systems/data-analytics-and-systems-group-dasg/data-analytics-systems-group-dasg-business-systems - Centers for Medicare & Medicaid Services. Medicare Program Integrity Manual, Chapter 2: Data Analysis.
https://www.cms.gov/manuals/downloads/pim83c02.pdf - Centers for Medicare & Medicaid Services. Data Analytics and Systems Group.
https://www.cms.gov/research-statistics-data-and-systems/data-analytics-and-systems-group - U.S. Department of Justice. National Health Care Fraud Takedown Results in 455 Defendants Charged in Connection with Over $6.5 Billion in Alleged Fraud. June 23, 2026.
https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-455-defendants-charged-connection-over-65 - Centers for Medicare & Medicaid Services. CMS Reports Highest Program Integrity ROI Ever Recorded. May 2026.
https://www.cms.gov/files/document/cpi-roi-fy25-pdf.pdf - U.S. Department of Health and Human Services, Office of Inspector General. Fraud, Waste, and Abuse for Health Care Providers.
https://oig.hhs.gov/reports/featured/ihs/fraud-waste-abuse-trainings/fraud-waste-and-abuse-for-healthcare-providers/
Dr. Ray Foxworth, DC, FICC, is the visionary behind ChiroHealthUSA, serving as its founder and CEO. With over 39 years of dedicated service in chiropractic care, Dr. Foxworth has navigated the complexities of billing, coding, documentation, and compliance firsthand. His experience includes roles as former Staff Chiropractor at the G.V. Sonny Montgomery VA Medical Center and past chairman of the Chiropractic Summit and Mississippi State Board of Health. He is an at-large board member of the Chiropractic Future Strategic Plan. Reach Dr. Foxworth at 1-888-719-9990, info@chirohealthusa.com, or www.chirohealthusa.com. Join a free weekly webinar on practicing with greater peace of mind: register at www.chirohealthusa.com.
