The neglect or failure of a carrier or self–insured employer to pay awards for medical bills in a timely manner has a significant impact on the ability of all injured workers to obtain effective and immediate treatment, as it discourages health care providers from seeking or retaining authorization to treat workers' compensation claimants. Additionally, it may result in the health care provider seeking direct payment from the claimant, despite the statutory prohibition against direct payments. A claimant's ability to obtain proper medical treatment expeditiously not only benefits the claimant, but also results in lower medical costs for employers. Claimants who receive prompt and proper attention are more likely to be able to return to work swiftly and less likely to have long term disabling conditions. The integrity of the workers' compensation system is compromised when carriers and self–insured employers do not meet their legal obligations to pay awards. The Board has received an increasing number of complaints by health care providers that bills rendered for the treatment and care of workers' compensation claimants are not being paid in a timely manner. In particular, providers are concerned that bills are not paid in many instances even after issuance of an administrative and/or arbitration award by the Board. Further, concern has been expressed that some bills are automatically rejected by the carrier due solely to a carrier's policy against paying bills for certain specific coded procedures, regardless of the apparent medical necessity for such treatments. It is the Board's intent that health care provider bills be paid in a timely manner after the carrier or self–insured employer has had a full and fair opportunity to contest the compensability or value of the bills if it elects to do so. Further, effective March 13, 2007, the Workers' Compensation Law, § 54–b was amended to authorize the Chair (or the Chair's designee) to issue a consent to file judgment when a carrier, self–insured employer or the State Insurance Fund fails to pay indemnity or medical benefits to a claimant or medical provider. Failure or neglect to pay awards for medical bills will be subject to judgment collection. In any case where the insurance carrier or self–insured employer has failed to make timely payments after an administrative or arbitration award and all appeals have been exhausted or no timely appeal has been taken, the health care provider may also seek to enter judgment for payment, pursuant to Workers' Compensation Law § 54–b. Workers' Compensation Law § 54–b specifically provides that in the event an employer or insurance carrier defaults in the payment of an award and/or an award of benefits made by the Board, any party to an award may, with the Chair's consent, file for judgment against the employer with the county clerk for the county in which the injury occurred or the county in which the employer has its principal place of business. Workers' Compensation Board authorized providers seeking payment of administrative and/or arbitration awards made on or after March 13, 2007 are asked to submit Form HP-J1, Provider's Request for Judgment of Award and to enclose a copy of the original award(s) issued. In order to allow for billing cycle payments, please allow 60 days after issuance of the administrative and/or arbitration award prior to requesting judgment. Send requests to: Workers' Compensation Board Bureau of Health Management Office of Health Provider Administration 100 Broadway – Menands Albany, NY 12241 The continued viability of the workers' compensation system is substantially dependent upon voluntary compliance of all parties with the Workers' Compensation Law, rules and regulations of the Board, and legal responsibilities imposed upon the parties. The Board remains committed to reducing adjudicatory delay and costs to all participants in the system. Self–insured employers and workers' compensation insurance carriers can contribute significantly to adjudication reform measures instituted by the Governor, the Legislature and the Board by meeting its obligations without the need to resort to extraordinary enforcement measures. If you have any questions, please contact the Office of Health Provider Administration at 1-800-781-2362. Zachary S. Weiss Chair

Given the failed efforts by Congress to avoid the looming cuts to the Medicare Physician Fee Schedule slated to take effect Tuesday, July 1, 2008, the Department of Health and Human Services (HHS) has intervened. The Agency announced that they would essentially freeze the Fee Schedule at its current levels for a period of ten days. That allows Congress three days to address the matter once they return from recess for the July 4th Holiday. Thank you to all of the ACA members who contacted your Members of Congress to request action. We will continue to keep you updated on any future action on legislation to address these draconian cuts.

Despite the aggressive efforts by ACA and its members, after multiple attempts by Congress, no agreement could be reached on legislation to avoid the looming cuts to the Medicare Physician Fee Schedule. The 10.6% across-the-board cut will go into effect on Tuesday, July 1, 2008. Doctors of chiropractic are urged to contact their local Medicare contractor or visit their carrier’s website for the most up to date information. Although the House of Representatives overwhelmingly passed legislation (355-59) earlier this week that would continue the Fee Schedule at its current levels through the end of the year, supporters in the Senate fell one vote short of overcoming a Republican filibuster. Leadership in the Senate has promised that they will revisit the issue when they return from next week’s recess for the Fourth of July Holiday. It is believed that any fix to be implemented would be retroactive to restore payments and compensate for the cuts. Some providers may wish to hold their claims until Congress acts to readjust the fee schedule. Thank you to all of the ACA members who contacted your Members of Congress to request action. We will continue to keep you updated on any future action on legislation to address these draconian cuts.

US Senate fails to pass a bill that would cancel the 10 percent cut scheduled to occur on Tuesday July 1, 2008. The bill would increase Medicare payments to doctors by 1.1 percent in January and cancel the 10 percent cut scheduled to occur on Tuesday. The President threatened to veto the bill, because it would reduce federal payments to private insurance plans, like UnitedHealth, Humana and Blue Cross and Blue Shield companies that offer Medicare Advantage plans.

37,000 Small Businesses in New York Will Receive Payments Refund Points to Need for Insurance Law Reform Governor David A. Paterson and New York State Insurance Department Superintendent Eric Dinallo today announced that Oxford Health Insurance, Inc. has agreed to refund $50 million to approximately 37,000 small businesses in New York City, Long Island and the northern suburbs for overcharging on health insurance policies in 2006. The refund highlights the need for legislation to reinstate the Insurance Department’s authority to approve rate increases before they go into effect, something the Insurance Department is pursuing this legislative session. Prior to 1996, the New York State Insurance Department had the authority to pre-approve rate increases for health insurance, a process that helped keep rates relatively stable for decades. Since the law was changed to eliminate the Insurance Department’s prior approval authority, the Department has only been able to look at the rate increases a year after they take effect. For more than a decade the only consequence for excessive rate charges has been repayment in subsequent years. “We must make New York a good place to do business by keeping costs competitive. We know that small businesses are the engine of growth in this State and the rising cost of health insurance is one of their major complaints,” said Governor Paterson. “If it can help protect business and keep premium rates down for New Yorkers, we should update the laws to give the Insurance Department more oversight.” Superintendent Dinallo said: “I am pleased that the Department was able to get these refunds for small businesses. But an after-the-fact settlement in 2008 does nothing for those businesses that may have had to drop coverage in 2006 because they could not afford a larger than necessary premium increase. These refunds would be unnecessary if the NYS Insurance Department had the authority to pre-approve rate increases for health insurance premiums. Requiring health plans to get approval from the Department before increasing rates would help keep New Yorkers insured. Lawmakers should restore to the Department the tools to better monitor and manage the marketplace for health insurance rates.” The $50 million settlement will be paid to 36,746 small business policyholders with approximately 300,000 employees and family members. The refund will vary depending on the number of covered individuals. It amounts to an average of $1,360 per business, which is about 5.5 percent of the total average annual premium in 2006. The Insurance Department initiated a review after Oxford reported to the Department that Oxford’s loss ratio for small group policies in 2006 was below the 75 percent minimum. Oxford paid benefits equal to 70.58 percent of its overall premiums in 2006. The vast majority of health insurers, like Oxford in this case, raise premium rates without first getting approval from the Insurance Department by utilizing a “file and use” procedure. If a health insurer using this method does not pay benefits equal to at least 75 percent of overall premiums in a calendar year, the insurer must refund the excess premium to policyholders in the form of cash payments or credits against future premiums. Superintendent Dinallo also said: “Oxford did the right thing in working with the Insurance Department to make sure consumers got their money back. But it is unfortunate the Department lacks the legal authority to pre-approve health insurance premium rate increases and prevent premiums that turn out to be larger than the law allows.” Elisabeth Benjamin, Director of Healthcare Restructuring Initiatives at the Community Service Society of New York, said: “This case just proves the old adage that ‘an ounce of prevention is worth a pound of cure. New York needs to revoke the insurance industry’s ‘E-ZPass’ on their ever-increasing rate increases. And the only way to do that is to restore the Insurance Department’s ability to approve rate increases in advance, and with public input.” The settlement affects policyholders of Oxford’s small group Freedom Plan Direct, Freedom Plan Metro and Freedom Plan EPO products. It does not affect Oxford’s small group and direct pay HMO and “point of service” (HMO/POS) policyholders. This case was handled for the Insurance Department by Deputy Superintendent and General Counsel Robert Easton, Deputy Superintendent for Health Troy Oechsner, Assistant Deputy Superintendent for Health John Powell, Deputy Bureau Chief Lou Felice, Chief Actuary Michel Laverdiere, Supervising Insurance Examiner Jim Carroll and Assistant Deputy Superintendent and Counsel Jon Rothblatt.

Former Gov. Eliot Spitzer charged Insurance Dept. Supt. Eric Dinallo to create new medical treatment guidelines. Mr. Bruce Topman was selected as the Chairman of a Workers Compensation Task Force which made recommendations to then Governor Spitzer and Mr. Dinallo in December 2007. The NYSCA has reviewed the Task Force's recommendatiions and questions the headlong rush to adopt medical treatment guidelines. It is the NYSCA’s understanding that the Workers’ Compensation Board is in the process of reviewing the guideline drafts provided by the Department as the Board toils with promulgating the regulations needed to implement the guidelines necessary to meet former Governor Spitzer’s agenda. In anticipation of the forthcoming rules and regulations, the New York State Chiropractic Association (NYSCA) offers the following observations giving voice to the profession’s concerns. The New York Chiropractic Council concurs with the NYSCA analysis and its conclusions. To view the entire NYSCA WC Position Statement click on the link below:

The OSMA-sponsored Healthcare Simplification Act (HB 125) will bring significant, positive changes to contracts between health insurers and physicians -- putting physicians on a more equal footing with the insurers. While the Healthcare Simplification Act will not address every problem you have with payers – it’s a good first step toward building a better way of doing business with insurance companies. The OSMA will not stop working on these issues until our members can enter into agreements with insurance companies that are fair, transparent, and simplify doing business. Most importantly, the agreements must be in the best interests of the doctor-patient relationship. The Healthcare Simplification Act (HB 125) Helps Physicians in Three Major Areas: • Transparency in Contracting • Fairness in Contracting • Standardized Credentialing Transparency • The Healthcare Simplification Act will ensure that physicians get a copy of the full fee schedule from HMOs, Third Party Administrators (TPAs) and other insurers, so that the physicians will know what they will be paid for their services. • The Healthcare Simplification Act requires HMOs, TPAs, and other insurers to provide physicians with a summary disclosure form of the contract that outlines, in plain language, important terms including: compensation terms, categories of coverage, duration of the contract, the entity responsible for processing claims, and the method of dispute resolution. The Act also requires specific notice be given to the physicians of any addenda to the contract. • The Healthcare Simplification Act restricts the selling or renting of a physician’s contract to another company unless the rental is disclosed and all of the terms of the original contract are honored. • The Healthcare Simplification Act prohibits “Most Favored Payer” clauses in contracts that force doctors to provide healthcare services at a lower price than originally called for in the contract. • The Healthcare Simplification Act requires insurance companies to notify doctors 90 days in advance of changes to a contract that either: decrease payment, increase administrative expenses or add a new product. • The Healthcare Simplification Act restricts the use of “all products” clauses that force physicians to participate in all of an insurer’s products. • The Healthcare Simplification Act prohibits an insurer from forcing a physician to accept their future product offerings. Standardization • The Healthcare Simplification Act designates the Council for Affordable Quality Healthcare (CAQH) credentialing form as the sole credentialing form to be used by insurers in Ohio. No additional information can be solicited by individual insurers from physicians seeking to be credentialed. • The Healthcare Simplification Act requires that all physicians be credentialed within 90 days. • The Healthcare Simplification Act establishes a $500 per day penalty or requires retroactive reimbursement if an insurer fails to meet the 90-day credentialing deadline.

Last week, CMS released a new Advanced Beneficiary Notice (ABN) form for use by Medicare providers. Of the key changes, the form includes a new title, “Advanced Beneficiary Notice of Noncoverage” and this most recent version may also be used for noncovered services, in place of a Notice of Exclusion from Medicare Benefits (NEMB). Medicare providers may begin using the new form at any time during this six month transition period, but CMS will only accept this updated version after September 1. To view and/or print the new ABN form, click below. For CMS instructions on completing the form, click below. For further information, please visit the CMS Web site.

Database Company Ingenix – Used by Dozens of Insurers – at Center of Scheme Cuomo Notifies Ingenix and its Parent, UnitedHealth Group, of Intent to File Suit; Subpoenas 16 Other Companies NEW YORK, NY (February 13, 2008) – Attorney General Andrew M. Cuomo today announced that he is conducting an industry-wide investigation into a scheme by health insurers to defraud consumers by manipulating reimbursement rates. At the center of the scheme is Ingenix, Inc., the nation’s largest provider of healthcare billing information, which serves as a conduit for rigged data to the largest insurers in the country. Cuomo also announced that he has issued 16 subpoenas to the nation’s largest health insurance companies including Aetna (NYSE: AET), CIGNA (NYSE: CI), and Empire BlueCross BlueShield (NYSE: WLP), and that he intends to file suit against Ingenix, Inc, its parent UnitedHealth Group (NYSE: UNH), and three additional subsidiaries. The six-month investigation found that Ingenix operates a defective and manipulated database that most major health insurance companies use to set reimbursement rates for out-of-network medical expenses. Further, the investigation found that two subsidiaries of United (the “United insurers”) dramatically under-reimbursed their members for out-of-network medical expenses by using data provided by Ingenix. Under the United insurers’ health plans, members pay a higher premium for the right to use out-of-network doctors. In exchange, the insurers promise to cover up to 80% of either the doctor’s full bill or of the “reasonable and customary” rate depending upon which is cheaper. The Attorney General’s investigation found that by distorting the “reasonable and customary” rate, the United insurers were able to keep their reimbursements artificially low and force patients to absorb a higher share of the costs. “Getting insurance companies to keep their promises and cover medical costs can be hard enough as it is,” said Attorney General Andrew Cuomo. “But when insurers like United create convoluted and dishonest systems for determining the rate of reimbursement, real people get stuck with excessive bills and are less likely to seek the care they need.” Cuomo’s investigation also found a clear example of the scheme: United insurers knew most simple doctor visits cost $200, but claimed to their members the typical rate was only $77. The insurers then applied the contractual reimbursement rate of 80%, covering only $62 for a $200 bill, and leaving the patient to cover the $138 balance. The United insurers and many other health insurance companies relied on the Ingenix database to determine their “reasonable and customary” rates. The Ingenix database used the insurers’ billing information to calculate a “reasonable and customary” rate for individual claims by assessing how much a similar type of medical service would typically cost, generally taking into account the type of service, physician, and geographical location. However, the investigation showed that the “reasonable and customary” rates produced by Ingenix were remarkably lower than the actual cost of typical medical expenses. The United insurers and Ingenix are owned by the same parent corporation, United HealthGroup. When members complained their medical costs were unfairly high, the United insurers hid their connection to Ingenix by claiming the rate was the product of “independent research.” The Attorney General’s notice to United expressed concern that the company’s ownership of Ingenix created a clear conflict of interest because their relationship gave Ingenix an incentive to set rates that benefited United and its subsidiaries. Cuomo’s notice of intent to sue names the following potential defendants: UnitedHealth Group and its subsidiaries, United HealthCare Insurance Company of New York, Inc., United Healthcare of New York, Inc., United Healthcare Services, Inc. and Ingenix. The subpoenas served today request documents showing how the insurer computes reasonable and customary rates, copies of member complaints and appeals, and communications with members and between Ingenix and the insurer on the issue. Cuomo continued, “The lack of accuracy, transparency, and independence surrounding United’s process for setting a ‘reasonable and customary rate’ is astounding. United’s ownership of Ingenix coupled with the inherent problems with the data it is using clearly demonstrate a broken reimbursement system designed to rip off patients and steer them towards in-network-doctors that cost the insurer less money.” Consumers Union Programs Director Chuck Bell said, "Based on the findings in this investigation, it appears that United Health failed to fulfill the promises it made to cover a fair portion of medical expenses, and consumers were stuck with the bill. The current process for establishing ‘reasonable and customary’ rates is riddled with conflicts of interest and manipulations that consistently lead to patients paying more, and insurers paying less. We applaud Attorney General Cuomo for taking on this issue which is vitally important for consumers everywhere.” Cancer Care’s Associate Executive Director Ellen Coleman said, “Cancer patients and others faced with life-threatening illnesses need to know that a fair portion of the often overwhelming medical expenses will be covered by their insurance company. Insurers should fulfill their promises and not leave patients forced to choose between the medical care they need and the medical care they can afford. Cancer Care thanks Attorney General Cuomo for taking action on this issue and for continuing to protect the rights of patients.” “The litigation initiated by the Attorney General is critically important for two reasons,” said Ron Pollack, Executive Director of the health consumer organization Families USA. “First, it is essential that health services obtained outside of a network be compensated fairly and adequately. Eighteen million Americans under the age of 65 will spend more than a quarter of their family income on health care this year, and healthcare debt is the number one cause of individual bankruptcy. Second, there needs to be transparency in these payment arrangements. For these reasons, we support the efforts of the Attorney General.” The American Medical Association's President-elect Nancy Nielsen M.D. said, “The investigation launched today by New York Attorney General Andrew Cuomo calls into question the validity of a system that health insurers have used for years to reimburse physicians and their enrolled members. Patients have a right to expect fair and accurate payment for services promised by health insurers. The AMA greatly appreciates the Attorney General’s interest and leadership in protecting consumers, and we offer our full cooperation in any effort to hold UnitedHealth accountable to New York state laws.” The Medical Society of the State of New York President Dr. Robert Goldberg said, “The Medical Society of the State of New York applauds Attorney General Cuomo and his hard-working staff for their diligent efforts in moving forward in an investigation that we believe will have long term benefits to healthcare in New York. MSSNY also applauds the Attorney General for acting on the complaints of our patients and our physician members.” The Attorney General’s industry-wide investigation is being handled by Acting Deputy Chief of the Healthcare Bureau James Dering as well as members of the Healthcare Industry Taskforce, Assistant Attorneys General Brant Campbell and Sandra Rodriguez, under the direction of the head of the Attorney General’s Healthcare Industry Taskforce, Linda Lacewell. Audio Attachments:

(Arlington, Va.) -- Congress, in one of its final acts of the session, passed legislation that temporarily halts a 10 percent across-the-board cut to the Medicare Physician Fee Schedule (MPFS). Instead, the bill will provide for a slight overall increase of 0.5 percent.

New York Attorney General sent a letter to the insurer’s UnitedHealthcare unit to cease the implementation of a program design to rank doctors according to quality and cost effectiveness. The attorney general is prepared to seek an injunction if UnitedHealthcare fails to comply with the request TO READ ATTORNEY GENERAL CUOMO'S LETTER TO UNITEDHEALTHCARE CLICK ON THE LINK BELOW

Any paper claims received by Medicare after June 29, 2007, must be submitted on the new version of the CMS 1500 form (08-05 version). If the old CMS form (version 12-90) is received by Medicare after June 29, 2007, the paper claim will be returned to the provider for resubmission on the new form. Medicare also requires the use of the National Provider Identifier (NPI) on paper claims as well as electronic claims. Be sure to denote your NPI on the new CMS 1500 forms on both electronic and paper claims.

New York State Insurance Superintendent Eric Dinallo today issued a plan to reform the resolution of disputed workers’ compensation claims. The plan substantially speeds the resolution of disputed claims from over 6-months to 90-days and was submitted in a letter sent on June 1, the deadline set by the Governor. The Superintendent outlined the reforms and their benefits in the letter and submitted an accompanying set of regulations. Resolving disputes faster is one part of the historic agreement between business, labor and government to reduce system costs to employers while increasing benefits to injured workers and getting employees back to work faster. "We are delivering on our promise to reform workers’ compensation in ways that both reduce costs to employers and increase benefits. This reform is an essential part of reviving the State’s economy and encouraging businesses to create more jobs here," Governor Eliot Spitzer said. "These reforms will significantly increase the efficiency and fairness of the system and accelerate the time it takes to get benefits to injured workers. Workers will be able to return to work earlier, system costs will fall and premiums will become more affordable for business owners. This is truly a win-win for employees and employers," Insurance Superintendent Dinallo said. "I would like to thank my staff and our advisors for their excellent and speedy work. We trust that we will be able to continue to find ways to improve the workers’ comp system thanks to the highly collegial and productive dialogue and process that we have with our advisors." On March 13, Governor Spitzer announced legislation to reduce the State’s high workers’ compensation costs for business, while increasing the State’s weekly payments to injured workers. By 2010 maximum benefits will rise to nearly $700 per week from only $400 today. The Governor asked Superintendent Dinallo to lead several reform efforts that further the legislative goals. The first task was reforming the adjudication process with a goal of reducing the time it takes to resolve disputed claims to 90 days. Currently, it takes more than 200 days. During this period, the injured worker may be receiving no cash payments or medical benefits. Delays in cash payments can cause serious financial hardship. Delays in receiving medical benefits and treatment can affect workers’ long-term medical prognosis and the ability to return to work. Under the current system, it is often not until the pre-hearing conference – an average of 75 days from the start of the claim – that the parties have sufficient information to evaluate their claims and defenses. It takes almost three more hearings for a typical claimant to establish a disputed claim and start the flow of benefits. In the 20 percent of cases that take more than three hearings, the average number of hearings is five. It can take up to 90 days to schedule each additional hearing. The newly proposed process will significantly accelerate resolution of disputed cases to within 90 days or less of the dispute. This will cut the time by more than half for the resolution of disputed claims. The reformed process was developed by the Workers’ Compensation Task Force led by Executive Director Bruce Topman after consultation with advisors designated by the Governor drawn from business labor, the legislature and executive departments. It sets specific time benchmarks for each stage of the proceedings, accelerates the time when evidence must be submitted and testimony taken, and requires professional representatives and medical providers to meet their responsibilities in a timely fashion, with consequences for not doing so. A major improvement will require employers, claimants and doctors to submit complete information up front. Early information substantially increases the opportunities for settling cases at an accelerated mediation session and at the pre-hearing conference. It also makes the trial-ready claim quicker and the initial evidentiary hearing follows within minutes of the pre-hearing conference. The proposed regulations accelerate claim resolution through earlier factual disclosure and assist injured workers in filing claims with all necessary information.

The American Chiropractic Association is urging doctors of chiropractic nationwide to take immediate action to provide documentation pertaining to the discriminatory practices of chiropractic networks. The investigation of these matters is becoming of national interest and we want to be ready to supply regulatory authorities with the information they need. Your assistance is needed by June 15, 2007. "Doctors across the country have the information that regulatory authorities need to address the serious problems posed by managed care organizations," announced ACA President Dr. Richard Brassard. "Many doctors have assisted us over the past two years in this long battle, but now more than ever, it is time for all doctors of chiropractic to take a stand to protect our patients and our profession. We have a real opportunity, one that we may not have again, to address the problems of these networks – and we cannot do it without help." ACA has been in communication with several state Departments of Insurance and Attorneys General regarding tactics by managed care networks that, in ACA’s view, limit reasonable and necessary treatment, placing effective patient care at risk. Our preliminary evidence gathered was used to petition these state regulatory agencies to investigate these practices. Recent indications received by ACA lead us to believe that state agencies are prepared to take a closer look in connection with these managed care networks. "The only way that state authorities will act is if they have the ‘ammunition’ to take on the powerful and wealthy managed care companies," added Dr. Brassard. "That ammunition is your patients’ records, which contain hard evidence on how managed care decisions have limited access to medically necessary chiropractic care that is provided for under plan descriptions and/or state law." To do your part and assist ACA and regulatory authorities with this historic investigation, we request that you take the following steps by June 15. (Documentation will continue to be collected after that date, but will be most useful before the deadline.) Read and sign the Business Associate Agreement (found here) creating an arrangement between you and the ACA, so that you do not need to sanitize records for this project or in the future. The purpose will always be for the Insurance Relations Department to investigate issues that impede patients obtaining the care they need. Note that all unsanitized patient records will be kept in a locked room in locked cabinets. Identify patients whose care or benefits have been compromised by coverage decisions made by managed care networks and speak with them to ascertain if they are interested in allowing their medical file to be shared with the ACA and regulatory authorities. A patient information sheet is provided (here) for your convenience. Only the ACA, State Departments of Insurance and State Attorneys General offices will be privy to the information in the patient records. No information regarding patients or their doctors will be shared with managed care companies. Obtain HIPAA Authorization: Explain HIPAA rights to the patient – (a brochure can be found (here) just in case you are unsure if your office documentation is up to date.) Once you are sure the patient clearly understands the reason for this initiative, and they indicate they would like to participate, have them sign the HIPAA Authorization (found here) which has been pre-completed for your convenience. Mail the following to the ACA: copies of your five complete unsanitized patient files with the associated HIPAA Authorization and your signed Business Associate Agreement to the following address: American Chiropractic Association Attention: Insurance Relations/Records 1701 Clarendon Blvd Arlington, VA 22209 If you are having trouble accessing the links above, all the referenced documents can be found on the ACA Web site at www.acatoday.org/datacollection For questions about this initiative, please e-mail [email protected] or call (703)276-8800 and ask to speak with someone in the Insurance Relations Department. Your assistance with this unprecedented data collection is appreciated. Together we can bring managed care abuses to light and with one voice share this information with those who have the power to bring change.

The New York State Chiropractic Association provides this information to you upon the request of, and as a courtesy to, the NYS Insurance Fund In its continuing effort to use technology to benefit policyholders, claimants and medical providers, New York State Insurance Fund CEO/Executive Director David P. Wehner announced that NYSIF has developed a state-of-the-art process for the electronic receipt of medical bills and accompanying reports. “I’m proud to announce medical bills are now being received without paper. This will definitely speed the bill-paying process while at the same time increasing accuracy. It’s a win for everyone. I congratulate our claims and information technology departments for their excellent work,” CEO Wehner said. NYSIF has selected two vendors, the Atlantic Imaging Group and P2P Link, to process bills and reports from providers and transmit them electronically to NYSIF where they will be logged-in and evaluated in an automated bill payment process. The new service is presently limited to bills submitted by providers using form CMS-1500, formerly known as HCFA-1500, or on a New York State Workers’ Compensation Board form C-4. NYSIF pays approximately 1.5 million bills per year. CEO Wehner says electronic receipt will ensure expedited and timely payments to medical providers and eliminate the need for them to place phone calls inquiring about the status of bills. “This represents a major improvement in customer service and provides more productive time for NYSIF’s claims professionals. CEO Wehner noted that NYSIF has been in the vanguard of insurance carriers finding innovative ways to integrate technology with the insurance business and the payoff has been remarkable for both the fund and its business partners. “Electronic receipt of bills is another major step forward.” The number of bills received electronically is expected to increase steadily as medical providers become familiar with the process and recognize its benefits. For additional information, contact Mr. Bob Lawson at 518 -437-3504

Insurance committee recently submitted a letter to Aetna which we hoped would persuade Aetna to re-assess their new 2007 PPO In-Network fee schedule. In the letter, we raised the five issues noted below: 1. Notification of Fee Schedule Changes: Fees were reduced without proper notification to your chiropractic panel members. Should participating doctors have advance notice to their fee schedule? If Aetna’s profitability falters, are Aetna’s salaried employees given notice prior to their reduction in salary or benefits? Even if there is found to be no legal obligation, is there no moral compulsion to treat in-network providers fairly? 2. Parasitic vs. a Symbiotic Relationship with Aetna Providers: Are In-network providers considered as members of the Aetna team? According to an Aetna press release (Feb. 8, 2007; found on the web at http://www.aetna.com/news/2007/pr_4thquarter2006_earnings.htm), there was a 29% increase in net operating income in 2006 vs. 2005. Why penalize members of your team, who in part, were responsible for this success? Philosophically, the survival of any provider contract should be predicated on a symbiotic relationship. If provider fees become predatory, then the relationship becomes parasitic and is doomed to failure. The desire to obtain short term financial gains may have dire long-term consequences, and the fall off may be precipitous rather than gradual. 3. Disproportionate Cutbacks in Chiropractic Reimbursement: Why were Aetna’s In-Network chiropractic codes reduced by 28%, while therapies and modalities were only lowered by 8 to 10%? Was this meant to be a direct assault on chiropractic? Is this in line with a pay-for-performance concept? Is this backed by the current literature or just performed at the whim of an anti-chiropractic stand by Aetna? If on the other hand, it is Aetna’s long-term goal to eliminate the chiropractic panel, then I see nothing wrong with your present tactics. Is Aetna’s long-term goal to eliminate the chiropractic panel? 4. Maintaining quality of care and subscriber enrollment: Being that there is no change in reimbursements to out-of-network providers (who receive ‘Reasonable & Customary”), are there any concerns as to attracting and keeping a high quality of provider within the Aetna network? I would think that a higher quality of provider leads to a higher patient satisfaction and more enrollees. A loss of good chiropractors from the panel can result in an attrition of Aetna enrollment (a reversal from the current trend). 5. Foster Team Spirit or Animosity & Resentment: In light of the fact that Aetna’s recent trend is toward greater (rather than lesser) profitability, In-network providers feel discouraged and betrayed by a lowering of their fee schedule. Both Aetna and Aetna’s providers are faced with increasing costs of operation; but whereas Aetna appears to be doing better, the same can not be said for their providers. The reduction just adds insult to injury, and fuels resentment as we care for your Aetna subscribers. Are In-Network providers considered part of Aetna’s team, or are we to be Aetna’s adversaries? The NYSCA has recently brought similar issues to another major carrier in the New York region, and they have agreed to return the fee schedule to the 2006 schedule. We sent a broadcast fax to all the chiropractors in NYS applauding the responsiveness of this Insurance Carrier. We will anxiously await your responses (or lack there of) so we can inform NYS chiropractors as to where Aetna stands on these issues discussed. Unfortunately, we just got word that Aetna will not change the new fee schedule, and Aetna has made a conscious decision not to respond to our letter as it can only lead to dissension. Many members are concerned that NYSCA is not fighting for our survival. Can members please send constructive suggestions as to how we might deal with situations such as this?

National Government Services, Inc. recently discovered a claims processing system problem that affected all Medicare Part B New York claims received on, or in process on, April 23, 2007 and April 24, 2007. The affected claims were denied incorrectly with remittance advice denial message CO-56, “claim/service denied because procedure/treatment has not been deemed ‘proven to be effective’ by the payer.” National Government Services is treating this problem with the highest priority and is in the process of identifying all claims that have been affected by this error. All impacted claims will be reprocessed. We recommend that you resubmit your claims if you received the CO-56 denial, but wait for National Government Services to perform the claim adjustments. We apologize for any inconvenience this may have caused. CPT codes, descriptions, and other data only are copyright 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.

The state senate has approved legislation sponsored by Sen. James L. Seward (R-C-I/Milford) that would create a state panel to review proposed health insurance mandated benefits to analyze their costs and impact on the cost of health insurance. Senate bill 3020 was approved by the senate unanimously. "Almost three million New Yorkers do not have health insurance, and for others, its rapidly escalating cost is putting affordable health coverage out of reach," Seward said. "Over the years the legislature has enacted legislation requiring that health insurance cover more than 30 different services, treatments and providers, and they all come with a cost." The legislation establishes the "health care quality and cost containment commission," the purpose of which is to analyze and report on the impact of proposed health insurance mandates. It would be charged with a) investigating the current practices of health plans; b) evaluating potential premium impact as well as avoided costs; c) analysis of current medical thinking to determine the mandate's affect on health care quality. The 2006-07 state budget includes a $300,000 appropriation for the commission, which would be included in the state insurance department. "Studies have shown that coverage of mandated services has increased premiums by 12 percent," Seward said. "And every one percent jump in insurance premiums means that 30,000 New Yorkers lose their health insurance. The commission will review mandates and advise the legislature on their estimated costs so that the legislature can make an informed decision on a particular mandate bill." The measure is sponsored in the assembly by Alexander "Pete" Grannis. "The best health insurance coverage is of no value if no one is able to afford it," Seward said.

ACN/Aetna Workers’ Compensation Access, LLC Program Last month, NYSCA sent out a notice concerning ACN’s mid-December mailing announcing a “new network access program” – the “Aetna Workers’ Compensation Access, LLC Program,” a Workers’ Compensation (WC) Preferred Provider Organization (PPO). Unfortunately, the NYSCA has learned, an ACN staffer gave out the wrong fax number participating providers to use if they were interested in opting-out of the ACN/Aetna program. Since the error was ACN’s, the NYSCA feels that ACN should honor opt-out requests sent and received already albeit to the wrong ACN facsimile number. Nonetheless, to be doubly sure that opt-out information has been properly received, the NYSCA recommends that providers re-fax their opt-out letters again to (763)595-3333, even if you sent an opt-out letter once already. It is the Association’s understanding the correct facsimile number for opting out of this program is (763)595-3333. Remember, this offer on the part of ACN and Aetna is not magnanimous. Everyone, but you and patients injured on the job, may benefit from this program. In theory PPO providers offer their services at a discounted rates with the hope of gaining a larger volume of covered patients attracted by the lower fees which more than offsets the discounts being offered. Although the theory works fine for payers, providers rarely see the boost in practice volume necessary to offset the loss in income from discounting their fees. Keep in mind too, that if you agree to join this Aetna/ACN WC PPO network your fees will be discounted off of the already low NYS WC fee schedule. As NYSCA noted before, one of the most frequent complaints the NYSCA receives questions why the chiropractic WC fees are so low and why they have not increased in more than ten (10) years. Furthermore, it is the NYSCA’s understanding that subsequent to the original ACN/Aetna mailing, ACN/Aetna sent out a revised fee schedule, one that more closely reflects the few services chiropractors can bill for under the NYS WC fee schedule. If you sign onto this program, in effect, you are directing Aetna/ACN to discount your already low WC fees. Caveat Scriptor. Remember too, to beware of fine print with hidden liabilities. By joining the Aetna WC PPO not only will signers discount their fees but they will be subject to other provisions of NYS Law embedded in the WC law. For example, the “Compliance” portion of the Appendix accompanying the ACN/Aetna solicitation references NYS WC Article 10A directing WC PPOs like the ACN/Aetna program to comply with other portions of NYS law, including Article Art 49 of the Public Health Law. Under Art. 49 Aetna/ACN WC PPO are “utilization review agents” required to “determine whether health care services that have been provided, are being provided or are proposed to be provided to a patient . . . are medically necessary.” By signing this agreement you will not only be agreeing to discount your fees but you will be agreeing to whatever treatment parameters Aetna/ACN decide are medically necessary for your injured WC patients. Caveat Scriptor. And as the NYSCA pointed out before, Aetna and ACN are not creating any new lines of business in New York. WC law already requires every employer to cover employee injuries received on-the-job either by self-insuring or through the purchase of WC insurance. Aetna and ACN are not adding any volume of new, untapped patients that you do not have access to already. To the contrary, Aetna and ACN are only creating new lines of business for themselves at your expense. They are offering your services at discounted fee$ to employers with the added prospect that utilization will be controlled as well. This inures to the benefit of Aetna/ACN and employers who contract with their WC PPO.its contracted employers. If you think you deserve le$ or that Aetna/ACN needs more profit at your expense, then . . . Caveat Scriptor. ACN Group has not been telling participating providers that they can opt-out of this program. In order to do so, it is the NYSCA’s understanding that participating providers must affirmatively opt-out by faxing a letter to the ACN Group at (763)595-3333 advising ACN/Aetna them that you “formally withdraw your participation in and from the Aetna Workers’ Compensation Access, LLC Program.” It is also recommended that you make clear your intent to remain in network with any other ACN Group products in which you are currently enrolled, if you choose to do so. Even if you sent an opt-out fax once already to the previous number ACN communicated in error, to be doubly sure your opt-out letter is properly received, the NYSCA recommends that you re-send your opt-out letter to the following number: (763)595-3333. For definitive opt-out information contact ACN Provider Services at 888-676-7768.

Arlington, Va. – Congress, in one of the final acts of the session, passed legislation that halts a 5 percent cut in Medicare physician fees. The reduction would have gone into effect on Jan. 1, 2007, in addition to the 8 percent cut doctors of chiropractic will incur in February 2007. Instead, the Tax Relief and Health Care Act of 2006, the omnibus bill that contained the physician fee provision, provides no increase in the congressionally mandated sustainable growth rate (SGR) mechanism which works to hamper spending in the Medicare program. The president is expected to sign the bill. “The ACA is pleased that Congress has halted this portion of the upcoming cuts in physician Medicare payments,” said ACA President Dr. Richard G. Brassard. “It is completely unreasonable to expect providers to take on further financial constraints when they are already being hit from all sides with fee decreases. We applaud this move as a significant recognition of the increasingly stressful environment for physicians in Medicare.” Although the Tax Relief and Health Care Act of 2006 provides some measure of relief, providers in Medicare still face many types of fee cuts for 2007. Under a final rule—issued by CMS per the congressionally mandated five-year review of the work values of billing codes—doctors of chiropractic will face an average 8 percent cut starting in February 2007. This rule also imposes significant cuts to radiological and imaging services. The bill also includes a provision that will allow for a 1.5 percent increase in reimbursement for providers who report on existing quality measures established by CMS. Quality measures are developed by several different organizations through a rigorous process grounded in evidence-based medicine. The measures, approved by CMS, are geared toward primary care practices and have been utilized in the Physician Voluntary Reporting Program. “The ACA will continue to lobby on behalf of its members for fair reimbursement of Medicare services. It is imperative that Congress and the Department of Health and Human Services develop a permanent solution to the physician fee schedule because those most affected by this annual dilemma are not doctors, but patients,” Dr. Brassard said. Because the fee schedule has many different components, including a geographic consideration, doctors of chiropractic should contact their local Medicare carriers/contractors for information on what their fees will be in 2007. The 8 percent decrease is only an average and percentages may vary depending on location. Therapy Caps For most chiropractors—with the exception of those participating in the Medicare Demonstration Project—coverage of chiropractic services is specifically limited to treatment by means of manual manipulation of the spine. However, the ACA has received numerous questions concerning therapy caps. Also included in the Tax Relief and Health Care Act of 2006, the President authorized CMS to continue an exception process for Medicare beneficiaries to apply for medically necessary therapy services if their treatment is expected to exceed the cap in 2007. The ACA will provide more information as it becomes available.