Previous controls have not done enough to reduce fraud and waste in connection to chiropractic care for Medicare patients, according to a review issued by a federal watchdog Friday.

The Department of Health and Human Services Office of Inspector General reported that Medicare continues to make millions in improper payments for chiropractic care and that a manual review process could save the agency big dollars by targeting medically unnecessary services.

Last week Forbes contributor Steven Salzberg, a Bloomberg Distinguished Professor of Biomedical Engineering, Computer Science, and Biostatistics at Johns Hopkins University, publicly slammed the Centers for Medicare & Medicaid Services for paying more than half a million on “pseudoscientific” chiropractic and osteopathic manipulation in 2015.

At the same time, health professionals and lawmakers are encouraging providers to consider chiropractic and related services as an alternative to opioids when treating chronic pain.

The American College of Physicians recommends non-drug treatments, including spinal manipulative therapy, before drug therapies for long-term care patients with lower back pain.

But the OIG’s portfolio identified vulnerabilities and reiterated recommendations from prior reports that have not been implemented or have been implemented ineffectively. It acknowledged that fraud, waste and abuse “is a concern.”

In addition, to further strengthen program integrity and facilitate the full implementation of our prior recommendations, the OIG reported that CMS should:

* Work with its contractors to educate chiropractors on the training materials that are available to them.

* Educate beneficiaries on the types of chiropractic services that are covered by Medicare, inform them that massage and acupuncture services are not, and encourage them to report to CMS chiropractors who are providing non-Medicare-covered services.

* Identify chiropractors with aberrant billing patterns or high service-denial rates, sample services provided by each chiropractor identified, review the medical records for the sampled services and estimate the amount overpaid to each chiropractor; and request chiropractors refund the amounts overpaid by Medicare.

* Establish a threshold for the number of chiropractic services that would trigger a medical review.