Filtered by category: Insurance News Clear Filter

ACA Insurance Relations: Important Decision Regarding Mechanical Traction

 

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Federal Agency Considers Further Chiropractic Coverage in Medicare

 

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Mandatory Use of Updated MTG Forms MG-1 and MG-2

 

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From the President: About that No-Fault regulation that takes effect on April 1, 2013...

On February 20, 2013, on behalf of the NYSCA membership, NYSCA President Dr. Bruce Silber wrote to the New York State Department of Financial Services seeking clarification of the, then, recently adopted No-Fault Regulation – FOURTH AMENDMENT TO 11 NYCRR 65-3 (INSURANCE REGULATION No. 68-C) Claims for Personal Injury Protection Benefits, I.D. No. DFS-20-12-00009-A, New York State Register, February 20, 2013, pp. 8-10.

In his query the Dr. Silber wrote:
As you may or may not recall, the New York State Chiropractic Association (NYSCA) offered comments on this regulation when it was first proposed last May. The Association has not received and has not seen any response to the observations the Association offered. The Association noted, however, that the State Register announced today (February 20, 2013) that the regulation has been adopted effective April 1, 2013.

In the meantime, a question has arisen regarding the regulation and how it will be implemented for which the Association seeks clarification. Specifically, the NYSCA seeks clarification of the following provisions:

New subdivision (g) of section 65-3.8 provides as follows:
(g) (1) Proof of the fact and amount of loss sustained pursuant to Insurance Law section 5106(a) shall not be deemed supplied by an applicant to an insurer and no payment shall be due for such claimed medical services under any circumstances:
(i) when the claimed medical services were not provided to an injured party; or
(ii) for those claimed medical service fees that exceed the charges permissible pursuant to Insurance Law sections 5108(a) and (b) and the regulations promulgated thereunder for services rendered by medical providers.

The problem area is (g)(1)(ii). Some NYSCA members have identified an ambiguity in the way these stipulations may be read.

On the one hand, it may be read that the regulation says that "no payment shall be due" for "those claimed medical service fees that exceed the charges permissible pursuant to the Insurance Law §§ 5108(a) and (b)" - that is, the WC fee schedule.

Specifically, §§ 5108(a) and (b) of Insurance Law stipulate as follows:

§ 5108. Limit on charges by providers of health services.
(a) The charges for services specified in paragraph one of subsection (a) of section five thousand one hundred two of this article and any further health service charges which are incurred as a result of the injury and which are in excess of basic economic loss, shall not exceed the charges permissible under the schedules prepared and established by the chairman of the workers' compensation board for industrial accidents, except where the insurer or arbitrator determines that unusual procedures or unique circumstances justify the excess charge.
(b) The superintendent, after consulting with the chairman of the workers' compensation board and the commissioner of health, shall promulgate rules and regulations implementing and coordinating the provisions of this article and the workers' compensation law with respect to charges for the professional health services specified in paragraph one of subsection (a) of section five thousand one hundred two of this article, including the establishment of schedules for all such services for which schedules have not been prepared and established by the chairman of the workers' compensation board.

Fees that are in "excess" - more than, above or beyond the amounts allotted in the Workers' Compensation fee schedule for individual services are not the real issue at hand here, although this is one way to read the ambiguity.

The concern that arises is that the Workers’ Compensation fee schedule permits doctors of chiropractic (and physical therapists) to be paid for only eight (8) units of treatment. Providers bill a combination of medically necessary therapies that oftentimes exceed the eight (8) units permitted. In addition, most electronic health care software programs follow the AMA CPT® coding rules and the software cannot be adjusted to bill only for, or exactly for eight (8) units or less when the services provided often tabulate for more. This is problematic since many practitioners provide and bill services in excess of the eight (8) units allotted pursuant to the revised and expanded Workers’ Compensation fee schedule. The Workers’ Compensation Board has accommodated the providers by allowing providers to bill for more than the eight (8) units payable but also stipulated that Workers’ Compensation payers would only be responsible for paying for maximum eight (8) units permitted.

If chiropractors (or physical therapists) provide and bill for services in excess of the eight (8) units allowed under the Workers' Compensation fee schedule, the No-Fault regulation adopted appears to allow insurers to deny payment automatically and in total, even though the dollar amount for services individually charged do not exceed the service dollar charges in the Workers Compensation fee schedule for those specific services.

The NYSCA does not contest the fact that providers should not be billing the payers of injured patients dollar amounts for individual and specific services that exceed the dollar amounts for individual services permitted by the Workers’ Compensation fee schedule. At the same time, however, the Association does not think it fair that the a provider’s payment could be automatically and completely denied should the practitioner provide and bill for services whose combined unit values go beyond the eight (8) units permitted by the Workers’ Compensation fee schedule, even though the dollar amounts (fees) for the individual services charges do not exceed and are consistent with the individual dollar amounts (fees) for those services found in the Workers’ Compensation fee schedule. This would be a disservice to the providers involved. If the eight (8) units of service carry over to the §§ 5108(a) and (b) fee schedule(s), then the Association feels that providers should be able to bill for services irrespective of the eight (8) unit service cap with the understanding that payers would only be obligated to pay for up to the eight (8) unit service limit.

Please clarify this ambiguity and how the Department intends on implementing this regulation.


As the deadline for implementation of the April 1, 2013 regulation looms, and not having heard from the Department of Financial Services relative to the Association’s February 20, 2013 inquiry above, I telephoned the Department of Financial Services and spoke directly to someone in the Insurance Bureau that works on No-Fault issues. After explaining the foregoing ambiguity again, the DFS representative explained that he believed the issue had been addressed in the State Administrative Procedure Act (SAPA) run-up to the regulation and that the Regulatory Impact Statement clearly states that ONLY the portion of a provider’s fee that exceeds the fee schedule will be denied, not the entire fee.

Not content to take the Department’s word, I looked up the Regulatory Impact Statement (RIS) directly and it seems to concur with the DFS statement. Under the rubric: “Preventing Billing in Excess of Mandated Fee Schedule or for Services Not Rendered,” the RIS states as follows:





























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Mandatory Payment Reductions in the Medicare Fee-for-Service Program – “Sequestration”

To All Health Care Professionals, Providers, and Suppliers

The Budget Control Act of 2011 requires, among other things, mandatory across-the-board reductions in Federal spending, also known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for two (2) months. As required by law, President Obama issued a sequestration order on March 1, 2013. The Administration continues to urge Congress to take prompt action to address the current budget uncertainty and the economic hardships imposed by sequestration.

This Listserv message is directed at the Medicare Fee-for-Service (FFS) program (i.e., Part A and Part B). In general, Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment. Claims for durable medical equipment (DME), prosthetics, orthotics, and supplies, including claims under the DME Competitive Bidding Program, will be reduced by two (2) percent based upon whether the date-of-service, or the start date for rental equipment or multi-day supplies, is on or after April 1, 2013.

The claims payment adjustment shall be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments.

Though beneficiary payments for deductibles and coinsurance are not subject to the two (2) percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the two (2) percent reduction. The Centers for Medicare & Medicaid Services encourages Medicare physicians, practitioners, and suppliers who bill claims on an unassigned basis to discuss with beneficiaries the impact of sequestration on Medicare’s reimbursement.

Questions about reimbursement should be directed to your Medicare claims administration contractor. As indicated above, we are hopeful that Congress will take action to eliminate the mandatory payment reductions.

Posted 03/08/2013.

Source: www.ngsmedicare.com

 

NGS Webinar - Medicare Documentation and Coverage

Medicare chiropractic service Documentation and Coverage
Join us for a Webinar on February 13

Space is limited.

Reserve your Webinar seat now at:
https://www1.gotomeeting.com/register/314303256
Medicare chiropractic service Documentation and Coverage

Title: Medicare chiropractic service Documentation and Coverage
Date: Wednesday, February 13, 2013
Time: 12:00 PM - 1:30 PM EST

After registering you will receive a confirmation email containing information about joining the Webinar.

System Requirements
PC-based attendees
Required: Windows® 7, Vista, XP or 2003 Server
Mac®-based attendees
Required: Mac OS® X 10.5 or newer
Mobile attendees
Required: iPhone®, iPad®, Android™ phone or Android tablet

 

ACA Files Class Action Lawsuit Challenging ASHN's, CIGNA's Improper Practices

Arlington, Va.--The American Chiropractic Association (ACA) has filed a class action lawsuit against American Specialty Health Inc. and American Specialty Health Networks Inc. (collectively, "ASHN"), and CIGNA Corporation and Connecticut General Life Insurance Company (collectively, "CIGNA"). The litigation alleges a litany of problems with the defendants, including arbitrary reductions of care, lack of communication to providers and patients resulting in coverage and payment errors, and interference with doctors' duty to exercise professional clinical judgment in managing patients' treatment plans.

Filed on Dec. 28, 2012, ACA's litigation--which is being handled by the law firm Pomerantz Grossman Hufford Dahlstrom & Gross LLP--represents a nationwide class of health care providers and subscribers who were subjected to ASHN and CIGNA's improper coverage and reimbursement practices.

Furthermore, CIGNA allegedly failed to comply with terms and conditions of its plan to afford its subscribers or their health care providers an opportunity to obtain a "full and fair review" of denied or reduced reimbursement, and to make appropriate and non-misleading disclosures to subscribers or their health care providers--an alleged violation of the Employee Retirement Income Security Act of 1974 (ERISA), the federal law governing private employee benefit plans. Additionally, the litigation outlines various allegations, including:
  • Use of false and misleading Explanations of Benefits relating to chiropractic claims (required under ERISA for informing subscribers of how their claims have been processed), which interferes with the doctor-patient relationship
  • Manipulating charge and payment data, allowing ASHN and CIGNA to pass on excessive costs to subscribers, while distorting the amounts providers actually receive in benefit payments
  • ASHN's restrictions of care via the pre-authorization process and provider contract provisions that prevent patients from having access to the full breadth of their benefits and in contradiction to their certificates of coverage--a violation of ERISA
  • ASHN and CIGNA's imposition of excessive co-pay requirements on subscribers, another ERISA violation
  • CIGNA's improper prevention of doctors of chiropractic (DCs) from providing services that fall within their scope of practice, in violation of state provider non-discrimination laws
  • ASHN and CIGNA's violation of various state prompt payment laws
ACA's suit requests the court to award injunctive, declaratory and other equitable relief to ensure ASHN and CIGNA's compliance with ERISA as well as other state and federal laws and regulations.

"ACA was compelled to take this action against ASHN and CIGNA because their egregious practices are undermining patient care and doctor-patient relationships. DCs feel they have to choose between acting in the best interest of the patient, and adhering to the requirements imposed by ASHN and payers they work with," said ACA President Keith Overland, DC. "Since 2002 we have worked to try and improve these issues. It is now time for action and we will not rest until patients across the nation receive all the care they need and have paid for through their insurance premiums."

Providers who believe they and/or their patients have been affected by ASHN and/or CIGNA's improper practices can visit the Chiropractic Networks Action Center where they will find instructions and forms that can be used to submit a complaint to ACA.

The American Chiropractic Association (ACA), based in Arlington, Va., is the largest professional association in the United States representing doctors of chiropractic. ACA promotes the highest standards of patient care and ethics, and supports research that contributes to the health and well-being of millions of chiropractic patients. Visit www.acatoday.org.

 

NGS Medicare Announces Important Updates Effective January 1, 2013

NGS Medicare has released several updates regarding changes that took effect on January 1, 2013. The principle highlights include the following:
  • The new fee schedule will be effective as of January 1, 2013, but is not published on the NGS web site at this time. For bookkeeping purposes, you may want to consider holding 2013 Medicare billings until later in the month. Check the website for updates.
  • Participation in PQRS is no longer optional as of January 1, 2013. Providers who do not report quality measures beginning January 1, 2013 will see a 1.5% fee reduction penalty starting in 2015.
  • EHR incentives are also still in effect with financial incentives available to those who qualify.
For more details on this release, please see the article below. Additionally, the New York Chiropractic College will be offering a NY Medicare educational program on January 10, 2013 at all locations. Among the topics to be covered are the Physician Quality Reporting System (PQRS), along with other Medicare procedures.

As always, the NYSCA will continue to send updates as we receive them.

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President Obama Signs the American Taxpayer Relief Act of 2012
--New Law Includes Physician Update Fix through December 2013--

On Wednesday, January 2, 2013, President Obama signed into law the American Taxpayer Relief Act of 2012. This new law prevents a scheduled payment cut for physicians and other practitioners who treat Medicare patients from taking effect on January 1, 2013. The new law provides for a zero percent update for such services through December 31, 2013. This provision guarantees seniors have continued access to their doctors by fixing the Sustainable Growth Rate (SGR) through the end of 2013...

Section 601 – Medicare Physician Payment Update – As indicated above, the new law provides for a zero percent update for claims with dates of service on or after January 1, 2013, through December 31, 2013. The Centers for Medicare & Medicaid Services (CMS) is currently revising the 2013 Medicare Physician Fee Schedule (MPFS) to reflect the new law’s requirements as well as technical corrections identified since publication of the final rule in November. For your information, the 2013 conversion factor is $34.0230.

In order to allow sufficient time to develop, test, and implement the revised MPFS, Medicare claims administration contractors may hold MPFS claims with January 2013 dates of service for up to 10 business days (i.e., through January 15, 2013). We expect these claims to be released into processing no later than January 16, 2013. The claim hold should have minimal impact on physician/practitioner cash flow because, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 for paper claims) after the date of receipt. Claims with dates of service prior to January 1, 2013, are unaffected. Medicare claims administration contractors will be posting the MPFS payment rates on their websites no later than January 23, 2013.

The 2013 Annual Participation Enrollment Program allowed eligible physicians, practitioners, and suppliers an opportunity to change their participation status by December 31, 2012. Given the new legislation, CMS is extending the 2013 annual participation enrollment period through February 15, 2013. Therefore, participation elections and withdrawals must be post-marked on and before February 15, 2013. The effective date for any participation status changes elected by providers during the extension remains January 1, 2013. (continued at http://bit.ly/2013MedicareUpdates)

 

One-Year Postponement in Medicare Reimbursement Cuts Included in Fiscal Cliff Package

The fiscal cliff legislation expected to be signed by the president today, contains a one-year delay in a scheduled cut in reimbursement for Medicare providers, including doctors of chiropractic.

The legislation will block a 27 percent payment cut to Medicare physicians that was due to start January 1st and keep rates frozen at current levels for the rest of this calendar year. Medicare providers were also set to face an additional two percent cut due to further budget tightening provisions, known as "sequestration," but that cut has also been suspended to give Congress time to find alternatives to this across-the-board cut in federal programs.

Once the fiscal cliff legislation has been signed, Medicare claims contractors will adjust their 2013 fee schedules accordingly; many have already removed the reduced 2013 fees from their web site so this adjustment can be made.  Please check your contractor's web site periodically for these new fees. Until the new fees are posted, the ACA recommends using the 2012 fee schedule.

 

Several Long Awaited Proposed Health Reform Regulations Released

Several long awaited proposed regulations that govern implementation of the Patient Protection and Affordable Care Act (PPACA) provisions were released by the Department of Health and Human Services (HHS) on Tuesday. These regulations are intended to provide detailed guidance regarding implementation of the 2010 law. Of special note--starting in Jan. 2014--it will be illegal for an insurer to discriminate due to pre-existing conditions in denying coverage. It is estimated that this one provision will provide insurance options for some 129 million Americans. In addition to the pre-existing conditions exclusion, insurers will not be able to discriminate based upon gender, occupation, claims history or health status for the purpose of raising premiums.

Additional Standards were also laid out in this week's proposed rule that relate to issuers' determinations of essential health benefits and their value. PPACA requires payers in the individual/small group markets to include within their plans core essential benefits. ACA is following this development closely and is active nationally on behalf of the profession. Be sure to look for ACA comments on these proposed rules in future editions of Week in Review. If you haven't yet decided to contribute to CHAMP, consider these national proposals and how they will affect you. Follow health care reform here.

 

Chairman Beloten Announces New Medical Treatment Guidelines for Workers’ Compensation

After continued conversations and meetings with the New York State Workers' Compensation Board, we are now able to confirm updates to the Medical Treatment Guidelines.

Effective February 1, 2013, regulatory changes will be made to the Medical Treatment Guidelines [MTGs] allowing for, among other things, maintenance care for chronic back and neck pain.  This is exciting news indeed!

Regulatory modifications to the MTGs include the following:
  • The new Carpal Tunnel Syndrome MTGs have formally been adopted. 
  • A new maintenance care program has also been adopted, allowing up to 10 visits per year for chronic pain for patients who have reached maximum medical improvement (MMI) and have a permanent disability. 
  • Variance Request transmission requirements are being clarified and simplified in order to reduce the number of technical violation rejections. Details regarding these changes will be released as they become available. 
  • Carriers are now permitted to grant a portion of a variance request. Providers and patients will have the right to request a review of any denied portion of the request. This new allowance provides an opportunity for providers and carriers to reach a compromise, resulting in a reduction in unnecessary litigation due to complete denials. 
It has been noted that, by far, the majority of variance requests (nearly 80%) submitted by providers have been for maintenance care for patients with chronic pain. The Medical Advisory Committee (MAC) continues to develop a chronic pain MTG. In the meantime, the MAC has agreed that some maintenance care (including chiropractic, physical therapy, and occupational therapy) should be available to patients with chronic pain who have received benefit from such treatment in the past. 

Accordingly, the revised MTGs will allow for up to 10 visits for maintenance care per year for patients who have reached maximum medical improvement (MMI) and have a permanent disability. These guidelines will apply to all claims effective February 1, 2013, regardless of the date of accident or the date of disablement.

Additional clarification is expected regarding the definition of “10 visits” (i.e. multiple body sites, CPT codes, and multiple provider types).  However, this is a move in the right direction and is a welcome change to the way workers’ compensation claims are currently administrated.

It is clear how beneficial these changes will be for injured workers and their providers:  The need for variance requests will be minimized or even eliminated for many patients; Employed patients will not have to lose time from work to attend hearings on denied requests; Recurrences of symptoms and exacerbations will be minimized, resulting in a better quality of life for our patients.

We anticipate that the Workers’ Compensation Board will continue to have open dialogue with the NYSCA and other vested organizations as we work together to serve the best interests of our patients and providers.

For more information, please see the official website of the New York State Workers Compensation Board:  http://www.wcb.ny.gov/content/main/SubjectNos/sn046_497.jsp

 

Combating Fraud and Abuse in Medicare & Medicaid

As Medicare Contracted Advisory Committee Representative for NY, Dr. Lupinacci and I have been receiving many complaints regarding Medicare. As CAC reps, we work closely on these issues with the ACA. We also get many questions as to what we are doing to stop some of the unfair treatment we receive in Medicare. Dealing with CMS and the rules and regulations governing Medicare is a national issue, we wanted to share a communication from ACA with you:

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Supreme Court Upholds Health Reform Law

ACA Will Continue to Fight for Patient Access to Chiropractic as Law is Fully Implemented 

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ACA's Investigation of ASHN Reveals Scope of Problems

 

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ACA, COCSA, OtherPlaintiffs Defeat UnitedHealthcare's Motion to Dismiss Class Action Lawsuit

Profession Can Now Pursue Alleged ERISA Violations   

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HHS Bulletin Outlines Plan for Implementing Essential Health Benefits in Health Law

Opportunities Look Bright for the Chiropractic Profession
 
The U.S. Department of Health and Human Services (HHS) today released a bulletin outlining proposed policies that will give states more flexibility and freedom to implement certain provisions of the Patient Protection and Affordable Care Act (PPACA). 
 
The HHS proposal describes "an inclusive, affordable and flexible proposal and informs stakeholders about the approach that HHS intends to pursue in rulemaking to define essential health benefits. HHS is releasing this intended approach to give consumers, states, employers and issuers timely information as they work toward establishing Exchanges and making decisions for 2014." This approach was developed with significant input from the public, including ACA's comments provided during the Institute of Medicine hearings, as well as reports from the Department of Labor, and research conducted by HHS. Today's HHS proposal offers for public comment four alternative "benchmark plans" for flexible choice by the states in designing how to meet the new health care reform essential health benefit (EHB) requirements.
 
Although the American Chiropractic Association's (ACA) leadership has just begun to analyze the HHS proposal, its first impression is positive for the chiropractic profession. "Overall, this is one of the best outcomes we could achieve," said Keith Overland, DC, president of ACA. "Given that virtually every state has chiropractic services or some sort of insurance equality included among their existing insurance plans; this HHS proposal released today appears to be very good news."
 
ACA understood in 2010 that the health care reform legislation was not likely to include chiropractic services as a named essential benefit. Therefore, its strategy has been to ensure that DCs are able to provide their services under the categories of EHBs included in plans offered through the health exchanges. "We will continue to make our position crystal clear at the highest levels of HHS-that language considered at the federal and state level relative to essential benefits must include the services provided by doctors of chiropractic. Anything less would be a disservice to the millions of Americans that benefit from chiropractic care on a daily basis," said Dr. Overland.
 
ACA and its Chiropractic Summit partners will examine the HHS proposal and, in partnership with the state associations, work to advocate that state governments  choose benchmark plans that include chiropractic services among the EHBs.
 
As projected by ACA, the HHS bulletin allows for public comment before Jan. 31, 2012. It is also expected that HHS will revert to the standard regulatory process on this issue next year, where further opportunity to comment will be available before a final rule is issued.

 
The American Chiropractic Association (ACA), based in Arlington, Va., is the largest professional association in the United States representing doctors of chiropractic. ACA promotes the highest standards of patient care and ethics, and supports research that contributes to the health and well-being of millions of chiropractic patients. Visit
www.acatoday.org.
















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Congress Passes Bill Delaying Medicare Cut

 

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New ABN form required as of Jan'12

Medicare has released a revised version of the ABN. They previously indicated that mandatory use of this version would begin on Nov. 1, 2011. Medicare has now delayed the implementation date to Jan. 1, 2012. All ABNs with the release date of March, 2008, that are issued on or after January 1, 2012 will be considered invalid.

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Daily News - New workers' compensation rules jeopardizing insurance for thousands of workers and retirees

 

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CBO: 30% Medicare Physician Pay Cut in 2012

According to a Congressional Budget Office (CBO) report released this week, Medicare payments to physicians will be reduced by 29.4% on Jan. 1. 2012, unless Congress takes action. 

The reduction is the result of several years of legislative action intended to either maintain or increase Medicare physician payments as those rates were scheduled to decrease according to Medicare’s Sustainable Growth Rate (SGR), a mechanism used to determine reimbursement rates.

There is general consensus that the SGR needs to be amended. Determining how best to change the formula has been the topic of numerous congressional hearings this year.  CBO's new report provides input into the costs of proposals to replace or amend the Medicare fee schedule formula. CBO reports that if Congress were to eliminate the SGR and freeze Medicare payments to physicians at current rates, the cost to the federal government would be almost $298 billion over 10 years. By contrast, providing a 2% pay increase each year until 2021 would cost $389 billion over 10 years. One of the less expensive options would be to reset the SGR by having Congress forgive all previous spending above the cumulative targets as of the end of 2010.  That solution would cost $195 billion over 10 years.



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