Filtered by category: Insurance News Clear Filter

NYSCA Comments Helps Prod Insurance Department Into Dropping Offending No-Fault Provisions

In response to comments the State Insurance Department (SID) received from the New York State Chiropractic Association (NYSCA) and other professional groups, individuals and organizations, on August 18, the Department published a “revised” regulatory proposal floated earlier this year that, among other things, would have pegged the fees for durable medical equipment (DME) at Medicaid levels, and, in one of the other more controversial amendments referred to as the "Concurrent Care Rule," would have required the “sharing of fees among licensed health providers or the payment of a fee only to the provider whose specialty was most relevant to the diagnosis, if more than one licensed health provider treated the patient at the same time, and the treatment involved overlapping or common services.” Read more in "Members' Only" section. Not a member? Consider joining NYSCA today to access this and other regularly updated information.



10 People, 5 Corporations Indicted For Operating Fraud Ring in Hollis, Queens Superintendent of Insurance Gregory V. Serio and Attorney General Eliot Spitzer today announced the indictment of 10 individuals and five corporations accused of operating an insurance fraud ring out of SZ Medical, a clinic in Hollis, Queens. The defendants include nine health care providers and are alleged to have fraudulently billed an insurance carrier for months of treatment and extensive testing, including medical evaluations, diagnostics tests, physical therapy, chiropractic treatment and acupuncture. Gregory V. Serio, Superintendent of Insurance, said, "It’s particularly disturbing that this fraud ring was comprised of doctors and health care providers, professionals who are here to protect us and not betray the public’s trust by defrauding our insurance system. Thanks to our strong partnership with Attorney General Spitzer, these people have been exposed and this case will help us build more momentum in the fight against fraud." "This case demonstrates the sustained and coordinated effort required to combat the pervasive nature of auto insurance fraud," Attorney General Spitzer said. "My office will continue to work with the State Insurance Department, law enforcement, and industry officials to bring these cases. While we are making progress, there is still an extraordinary amount of work yet to do." Under the State's no-fault auto insurance law, insurance carriers reimburse medical facilities for services provided to persons injured in motor vehicle accidents. It is alleged that the defendants submitted fraudulent claims to a no-fault insurance carrier for services never provided or for services that were not medically necessary. The charges stem from a long-term investigation of SZ Medical which began in Spring, 2003. According to the indictment, the defendants fraudulently billed an insurance carrier for months of treatment and extensive testing, including medical evaluations, diagnostics tests, physical therapy, chiropractic treatment and acupuncture. The indictment charges that fraudulent claims were submitted by three medical doctors, Sergey Zavilyansky, 48, of Brooklyn; Gary Friedman, 51, of Manhattan; and Lee Craig Nagourney, 52, of Brooklyn. Zavilyansky is the owner of SZ Medical. All three are charged with fabricating medical diagnoses and submitting claims for services not provided or not medically warranted. The indictment additionally charges the following defendants with fraudulent claim submissions: Stanley Frankel, 69, of Manhattan, a dentist; Michael Ferrato, 56, of Suffolk County, a psychologist; Juby Uralil, 26, of Queens County, a physical therapist; Joel Santos, 34, of Queens County, a physical therapist; Peter Pramberger, 51, of Suffolk County, a chiropractor; and Ji Yong Kim, 39, an acupuncturist. The indictment also charges that defendant Nelson Bloom, 57, of Brooklyn, a paralegal, held himself out as a licensed attorney and directed a no-fault patient to undergo medical tests and attend the clinic for several months, without regard to medical need, in an effort to increase the potential settlement of a bodily injury claim. Five corporations are also charged in the indictment: SZ Medical, P.C.; Almaz Medical Services, P.C., owned by physician-defendant Lee Craig Nagourney; Ferrato Psychological Services, P.C., owned by psychologist-defendant Michael Ferrato; Life Chiropractic P.C., owned by defendant Peter Pramberger; and Somun Acupuncture, P.C., owned by acupuncturist-defendant Ji Yong Kim. The defendants are facing charges of Insurance Fraud in the Third Degree, a D felony; Insurance Fraud in the Fourth Degree, an E felony; Falsifying Business Records in the First Degree, an E felony; Insurance Fraud in the Fifth Degree, an A misdemeanor, Attempted Grand Larceny in the Fourth Degree, an A misdemeanor; Practicing or Appearing as an Attorney-At-Law Without Being Admitted and Registered, an A misdemeanor; Conspiracy to Commit Grand Larceny in the Fourth Degree, an A misdemeanor; and Attempted Petit Larceny, a B misdemeanor. New York is aggressive in its fight against insurance fraud. To report suspected incidents of insurance fraud call 1-888-FRAUD-NY (1-888-372-8369). It should be noted that an arrest is merely an accusation and that a defendant is presumed innocent until proven guilty.

Read More


A chiropractor, licensed or legally authorized by the state or jurisdiction of service, may provide treatment only in the form of manual spinal manipulation to correct a subluxation (provided such treatment is legal in the state where it is performed). Specifically, Medicare defines chiropractors, based on §18601(r) of the Act, as physicians with respect to treatment by means of manual manipulation of the spine (to correct a subluxation) which he is legally authorized to perform by the state or jurisdiction in which treatment is provided. The following article addresses the ordering of X-rays for chiropractic patients. Read more in the Member's Only News Section. If you are not a member, join the NYSCA today and obtain access to the full story above.



The New York State Court of Appeals’ June 10, 2004 decision in Belmonte v. Snashall affirmed the New York State Workers’ Compensation Board regulations regarding independent medical examinations, specifically the definition of “board certified” contained in the regulations. The regulations define the term “board certified” as a “physician or surgeon who is certified by a specialty board that is recognized by the American Board of Medical Specialties or the American Osteopathic Association.” Please be advised that because the physicians listed below do not currently satisfy the “board certified” requirement in the regulations as they are not certified by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA), their temporary authorizations to perform independent medical exams have been revoked, effective July 1, 2004. Reports of examination conducted through June 30, 2004 are permitted and the physicians entitled to payment. In addition, testimony and/or depositions concerning independent medical examinations conducted through June 30, 2004 may be provided. Revoked Independent Medical Examinations Authorizations Dominic John Belmonte, MD Donald J. Cally, MD Barry Constantine, MD Arthur Dinoff, MD Harvey Fishman, MD William J. Kilgus, MD Jose R. Lopez-Reymundi, MD Lawrence E. Miller, DO James W. Nelson, MD Jay Alan Rosenblum, MD Librada M. Santos, MD Any questions regarding this matter should be referred to the Office of General Counsel at 518-486-7676. David P. Wehner Chairman


Effective June 26, 2004, the New York State Workers’ Compensation Board is rescinding the designation of Northeast Medical Evaluation and Diagnostic Services, P.C. as an entity registered to derive income from independent medical examinations in workers’ compensation cases. This rescission is made pursuant to Section 13-n of the Workers’ Compensation Law and 12 NYCRR 300.2 (e). This rescission is permanent. The entity’s address is: Northeast Medical Evaluation and Diagnostic Services, P.C. 900 Merchants Concourse Westbury, New York 11590 On the effective date of this rescission, the entity named above is permanently prohibited from deriving income from independent medical examinations in workers’ compensation cases. Examinations conducted prior to June 26, 2004 are valid. Any questions regarding this matter should be referred to the Office of General Counsel at 518-486-7676. David P. Wehner Chairman

ACA, VCA To Petition U.S. Supreme Court in Trigon Case

ARLINGTON, VA - The American Chiropractic Association (ACA) and the Virginia Chiropractic Association are set to petition the U.S. Supreme Court to hear the federal antitrust and racketeering lawsuit against Trigon Blue Cross Blue Shield after the U. S. Court of Appeals for the 4th Circuit on June 2 rejected a petition to rehear the case. "The actions of the 4th Circuit were not entirely unexpected, since U.S. Courts of Appeal are reluctant to revisit decisions that have been handed down by any panel," said ACA Chairman of the Board George McClelland, DC. "This only strengthens our resolve to continue this important legal struggle and seek justice for our patients and our profession from the highest court in the land - the U.S. Supreme Court." The issues raised in the petition, however, suggest a direct conflict between the decision of the U.S. Court of Appeals for the 4th Circuit and the two decisions of Supreme Court of the United States [Copperweld Corp. v. Independence Tube Corp., 467 U.S. 752 (1984) and U.S. v. Paramount Pictures, Inc., 334 U.S. 131 (1948)], as well as a direct conflict between the decision of the 4th Circuit and a decision of the U.S. Court of Appeals for the 6th Circuit [Nurse Midwifery Assoc. v. Hibbett, 918 F.2d 605]. Both are issues that are frequently examined by the Supreme Court of the United States: (1) a lower court being out of sync with a controlling decision of the Supreme Court, and/or (2) a conflict between two lower courts of appeal requiring refereeing by the Supreme Court to establish which court of appeals decision and reasoning is correct. The ACA cites in its lawsuit that a conspiracy existed between Trigon and the medical specialty societies in Virginia to ensure that patients with musculoskeletal conditions were diverted to medical doctors instead of doctors of chiropractic. A key piece of evidence in ACA's case was the existence of a committee established by Trigon to review low-back guidelines published in 1994 by the federal government's Agency for Health Care Policy and Research (AHCPR) - guidelines favorable to chiropractic - and to recommend appropriate protocols for referring patients to chiropractic doctors. The committee was appointed from a pool of representatives recommended by medical specialty associations from throughout the state of Virginia. No doctors of chiropractic were appointed to the committee and no chiropractic associations in Virginia were given the opportunity to submit names of nominees to the committee. As a result, the committee published guidelines that did not mention the positive effects of spinal manipulation that had been a highlight of the AHCPR report. The committee instead diminished spinal manipulation's value, and in doing so, essentially invalidated a legitimate federal study, according to the ACA. The Court of Appeals found that the committee was an agent of Trigon - not a separate entity - and therefore no conspiracy existed. Instead, the court likened Trigon's actions to a hospital's credentialing "peer review" process - in which a group of medical physicians determines the qualifications of other medical doctors who are candidates for employment. The ACA believes a conspiracy did exist, and it is inappropriate to compare a hospital's credentialing review process to the types of coverage, payment and referral policy making decisions engaged in by Trigon and the selected medical societies. "We want to bring Trigon's harmful and discriminatory practices to an end, but, equally important, we must keep in mind the big picture," added Dr. McClelland. "We must send a strong signal to all who would seek to oppose, harm, or discriminate against us: we will never give up and will always fight back." The ACA and other plaintiffs have 90 days to petition the Supreme Court of the United States for review.

Medicare Service Specific Review of 98941

The NYSCA received the following letter and guidance from the Upstate Medicare Division Contracted Carrier, HealthNow. The letter is self-explanatory. This information is being supplied to you at the request of HealthNow. Please review the attached information and if you have any comments or questions please feel free to contact Barbara Adams, LPET Specialist at the number contained in the letter. Alternatively, you may elect to contact NYSCA’s Medicare Chairperson and CAC representative, Dr. Peter Pramberger at the following telephone exchange: 516-741-2940.


WASHINGTON - During a public meeting today, the U.S. Equal Employment Opportunity Commission (EEOC) voted to approve a proposed final rule that would permit employers, under the Age Discrimination in Employment Act (ADEA), to lawfully coordinate retiree health benefit plans with eligibility for Medicare or a comparable state-sponsored health benefit. This common and long-standing employer practice was called into question in 2000, when the U.S. Court of Appeals for the Third Circuit (Erie County Retirees Association v. County of Erie) held that the federal statute requires employers to assure that pre- and post- Medicare eligible retirees receive health benefits of equal type and value. "This rule is intended to ensure that the ADEA does not have the unintended consequence of discouraging employers from providing valuable health benefits to retirees," said Chair Cari M. Dominguez, emphasizing that the General Accounting Office has estimated 10 million retired individuals aged 55 and over count on employer-sponsored health plans as either their primary source of health coverage or as a supplement to Medicare. "Such benefits are provided on a voluntary basis at the discretion of each employer and the Commission is acting to preserve these valuable benefits for retirees." "We know that health benefits are very important to retirees. Our proposal permits the common-sense practice of coordinating employer-provided retiree health benefits with eligibility for other benefits to continue," added Vice Chair Naomi C. Earp. "This rule should be welcome news for America's retirees." The Commission's prior policy, which was rescinded by a unanimous vote in August 2001, had concluded that coordinating retiree health benefits with Medicare eligibility constituted an illegal age-based distinction under the ADEA. A Notice of Proposed Rulemaking published in the July 14, 2003, Federal Register solicited public comments on the document discussed and voted upon today. The approved proposal now will be submitted, under Executive Order 12067, to federal agencies for final review and any comments they may wish to submit. Pursuant to Executive Order 12866, a review at the Office of Management and Budget will follow. After interagency review, a final rule will be published in the Federal Register. Only after all of these steps occur will the rule become final. In addition to enforcing the ADEA, which prohibits age discrimination against workers age 40 and older, the five-member Commission enforces Title VII of the Civil Rights Act of 1964; the Equal Pay Act of 1963; Title I of the Americans with Disabilities Act of 1990; portions of the Rehabilitation Act of 1973; and sections of the Civil Rights Act of 1991. Further information about the EEOC is available on the agency's web site at:



The transcript of the oral arguments presented before the 4th Circuit Court in Richmond, VA, on February 24th by ACA and Trigon are now available on ACA's Web site.


Veteran Attorney McAndrews Fights for Trigon Appeal Before Three-Judge Panel

ARLINGTON, VA — With his characteristic repertoire of blistering truths and colorful analogies, ACA General Counsel George McAndrews pulled out all the stops Feb. 24 to convince a federal three-judge appellate panel that insurance giant Trigon Blue Cross Blue Shield conspired to discriminate against doctors of chiropractic. During the hearing in Richmond, VA before the U.S. Court of Appeals for the 4th Circuit, McAndrews presented oral arguments laying out the reasons why he believes the case deserves to be sent back to the district court for trial. "Once in a while, everything needs to default to common sense," McAndrews implored the judges. "To say there is no conspiracy here ignores reality." During the hearing, McAndrews and attorneys for Trigon each had a total of 20 minutes to state their cases and respond to questions from the judges. McAndrews used 14 minutes of his time to present evidence that Trigon had altered the federal government's 1994 guidelines on acute low back pain to remove reference to chiropractic-style spinal manipulation — purely for economic reasons. Trigon's new "referral" guidelines, co-authored by representatives of most of the state's medical physician trade associations and medical schools, effectively directed low back patients away from chiropractors and to pharmaceutical treatment by medical doctors, he said. McAndrews then saved his six remaining minutes to use for rebuttal following Trigon's presentation. "They changed the critical definition of manipulation," McAndrews explained. "The evidence is that they weren't trained in [manipulation]. It was panic time." During their 20-minute presentation, Trigon attorneys contended there was no evidence of a conspiracy and that doctors of chiropractic were paid less than medical doctors because they are not as highly educated. According to Trigon attorneys, a for-profit company such as Trigon has every right to make business decisions that it feels make the best business sense. During his rebuttal time, McAndrews challenged the Trigon attorneys' assertion that doctors of chiropractic are less educated and should therefore make less money than medical doctors. McAndrews explained that, while the medical doctors controlling Trigon base their decisions to discriminate against doctors of chiropractic on monetary issues, professional pride also comes into play. McAndrews quipped that medical doctors/M.D.s see themselves as "Major Deities," but they sneer at other professionals with doctoral degrees, including judges and attorneys who have J.D. degrees, as merely "Just Docs" — a statement that elicited knowing chuckles from the judges. McAndrews concluded by emphatically reiterating that Trigon's and its medical physician co-conspirators' actions constituted medical fraud and were based on "pure economic greed." He reminded the court that every person who has ever been mistreated by under-educated medical doctors for musculoskeletal problems and has had to endure unnecessary pain, surgery or work or social disablement from the mistreatment were silent witnesses to this lawsuit. After the hearing, McAndrews had positive comments about the process. "We were impressed by the depth of knowledge shown by the panel," he said. "It is clear that they carefully read our briefs and were prepared to ask knowledgeable questions about the legal conflict that exists between medical doctors and chiropractic doctors. They questioned both sides fairly and I can only hope that common sense prevails. It appeared that the court was very bothered that the chiropractic doctors were left with no apparent recourse or remedy for a rather apparent series of wrongs perpetrated by Trigon and its co-conspirator medical trade associations." A full courtroom — with many supporters from the chiropractic profession — was on hand to witness this historic event. In addition to McAndrews' legal team, spectators included ACA President Donald J. Krippendorf, DC, ACA Chairman George B. McClelland, DC, ACA Executive Vice President Garrett F. Cuneo, ACA Legal Counsel Tom Daly, ACA Media Spokesperson Jerome McAndrews, DC, Former ACA Chairman Louis Sportelli, DC and ACA Vice President of Communications Felicity Feather Clancy. A decision about the case from the appellate court could be rendered within one to six months after the oral arguments. For a full copy of the appeal brief, click here. In addition, a full transcript of the Feb. 24 oral arguments will be available on ACA's Web site in approximately one week. The National Chiropractic Legal Action Fund (NCLAF) has been established to support ACA's federal chiropractic lawsuits on behalf of the profession. Doctors, patients and other concerned individuals may contribute to the fund by making a donation online or sending a check to NCLAF, P.O. Box 75359, Baltimore, MD 21275.

Growing medical costs seen as No. 1 workers comp trend

BOSTON (Nov. 10, 2003)-The most important nationwide trend affecting workers compensation this year has been increases in medical costs, according to panelists speaking during the recent Business Insurance's Workers Compensation and Disability Management Conference. This "most critical" trend means that the cost of caring for injured workers' medical needs is now a larger part of each workers compensation claim dollar, said Nancy Schroeder, assistant vp-workers compensation for the National Assn. of Independent Insurers in Des Plaines, Ill., who addressed the conference late last month in Boston. According to data from the National Council on Compensation Insurance, "medical claim costs are alarming, with double-digit increases the last two years. In 2002, medical severity increased by 12%, even greater than the 2001 increase of 10.7%." Yet it is important to remember that comp care "represents only 3% to 4% of total health care expenditures," said Keith Bateman, vp and director of the Alliance of American Insurers in Downers Grove, Ill. Several factors contribute to the increasing health care costs of workers comp claims, Mr. Bateman said. While costs are up for inpatient hospital stays and specialists' fees, the increased cost and utilization of prescription drugs makes that the key contributor, he said. What's particularly troublesome for workers comp insurers is that many of the tools available to control drug spending in group health plans, such as worker co-payments and the ability to direct an employee to a particular pharmacy, are not available to them (BI, Oct. 20). In addition, employers and insurers are grappling to cope with the growing use of the painkiller OxyContin. The drug, which was originally intended for people suffering from severe long-term pain, has become one of the most popular drugs prescribed for workers comp claimants. The concern with the drug stems from its addictive nature and how some users are abusing it. Some claimants who use it become addicted while recovering from their injuries and then must go through a detoxification program before they can return to work, Ms. Schroeder said. In addition, the slow-release medication can produce a heroin-like high when consumed after being ground up. It has a street value of 10 times its cost, which may entice some workers to make money by selling it, Ms. Schroeder said. But rising medical costs are not the only national trends that have emerged this year, Ms. Schroeder said. Another trend concerns federal impingement on state workers comp programs, she said. That "is an increasing and disturbing trend," said Bruce C. Wood, assistant general counsel with the Washington-based American Insurance Assn. One of the most serious examples of that is the federal Medicare program's "far more aggressive stance" in protecting its status as "the secondary payer" of benefits to previously injured workers, he said. Consequently, Medicare is requiring employers to establish trust funds to pay the medical costs of older injured workers to help ensure that employers and their workers comp insurers primarily pay such costs, so that they are not left to Medicare, he said. The Medicare secondary-payer issue "has been increasingly disruptive" and is expected to continue because Medicare is going broke at the same time Congress is expanding the drug benefit Medicare offers under its program, Mr. Wood said. Lobbying efforts heretofore have not resolved the problem, so the next step is to get Congress to step in and define Medicare's appropriate interest in a state-based workers comp system, he said. Another example of federal impingement is a bill (H.R. 1562) approved by the House Veterans' Affairs Committee that could allow veterans to receive medical care for workers compensation claims through the U.S. Veterans' Administration. It also would permit that entity to recover full charges for any such medical care, which could increase workers comp costs, Mr. Wood said. Despite those infringement issues, some progress has been reported in resolving workers comp payers' concerns about their continued access to claimants' medical data, following enactment of the Health Insurance Portability and Accountability Act earlier this year. Payers need access to such data to resolve claims and had been concerned that physicians might respond to the privacy requirements by denying information to them, although the law's preamble expressly excludes applying those provisions in the case of workers compensation claims, Mr. Wood said. While there have been pockets of problems, the education effort appears to be succeeding, Mr. Wood said. Another national trend concerns various types of activity involving state-specific funds, which generally exist at least to provide a source of workers comp coverage, if none is available elsewhere. Developments this year include concerns about the solvency of the competitive California state fund, which, if declared insolvent, could "take down" private insurers linked to it by guaranty funds, Mr. Bateman said. Meanwhile, the Arizona state fund is suing legislators who sought to use its accumulated assets for general expenses, he said. In several states, though, there have been proposals to allow a fund to write others lines of insurance, such as medical malpractice insurance in Oregon, he said. Finally, workers comp insurers continue to be concerned about state funds that seek to write workers comp insurance outside their borders while still maintaining their federal tax exemption, he said. That exemption reduces their cost of operation relative to their private insurers, who have complained that their entry into the marketplace constitutes unfair competition. This information is reprinted with permission of the Business Insurance. Copyright 2004. To learn more visit Business Insurance website:



Governor George E. Pataki today nominated State Department of Labor veteran David Wehner to be the next Chairman of the New York State Workers’ Compensation Board. His nomination is subject to confirmation by the New York State Senate. “David Wehner’s extensive experience and expertise in labor and other work-related issues make him ideally suited to lead the Workers’ Compensation Board,” Governor Pataki said. “The Workers’ Compensation Board is one of our most efficient, responsive and well-managed agencies, and I am confident that the high standards of excellence set by former Board Chairman Robert Snashall will continue under David’s leadership.” “I also want to commend Interim Board Chairman Jeffrey Sweet for the steady job he did while the search was underway for a new Chairman,” Governor Pataki said. “I’m pleased he will continue to serve on the Board as Vice Chairman, and I know David and Jeff will make an outstanding team.” David Wehner said, “I am honored Governor Pataki has nominated me as Chairman of the Workers’ Compensation Board. Since 1995, there have been many legislative and administrative changes implemented under Governor Pataki, which have greatly improved the Board’s delivery of services across the state. I am looking forward to the opportunity to continue that success.” Wehner, who currently serves as Executive Deputy Commissioner at the New York State Department of Labor, fills the vacancy left by Robert Snashall’s departure as Board Chairman last year. Jeffrey Sweet, Vice Chairman of the Board, has been serving as Interim Board Chairman since Snashall left last August. Mr. Wehner has served as Executive Deputy Commissioner since 2001. As Executive Deputy Commissioner, he has been responsible for the daily operations of a $6.5 billion agency, including 60 local offices across the State and more than 4,500 employees. Mr. Wehner has oversight for the unemployment insurance, employment service, welfare-to-work, job training, Workforce Investment Act, public safety and health, and worker protection programs in New York State, as well as serving as department liaison to the labor and business communities. Before being named Executive Deputy Commissioner, Mr. Wehner had served more than three and a half years as Deputy Commissioner for Administration and Public Affairs. Previously, Mr. Wehner also served as both Chief Special Assistant to the Commissioner of Labor and Director of Communications. In that capacity, he was responsible for policy oversight, intergovernmental relations and the communications functions of the department. --more-- He is a member of the Board of Directors for the National Association of State Workforce Agencies (NASWA), and past President of the National Association of Government Labor Officials (NAGLO). Mr. Wehner is a native of Rochester, and holds a Bachelor’s and Master’s Degree in Communications from the State University of New York at Albany. Mr. Wehner and his wife, Diane Wallace Wehner, live in Guilderland with their two sons, Paul and Kevin, and daughter Allison. As Chairman of the Workers’ Compensation Board, Wehner will earn an annual salary of $120,800.

Record Fine against CIGNA Healthcare and CIGNA Behavioral Health

Superintendent of Insurance Alessandro A. Iuppa announced that CIGNA Healthcare of Maine, Inc., and CIGNA Behavioral Health (collectively "CIGNA") have been fined a total of $900,000 for multiple violations of Maine law. The fine, which was assessed as part of a consent decree with the companies, constitutes the largest fine ever levied by the Maine Bureau of Insurance. CIGNA Healthcare of Maine, Inc. holds a certificate of authority to operate in Maine as a health maintenance organization ("HMO"). CIGNA Behavioral Health holds a license as a medical utilization review service that reviews the necessity, use, or appropriateness of behavioral health care services, and as a third-party administrator. The companies were found to have violated Maine law for failing to pay claims on time, failing to pay interest due, failing to keep supporting claim documentation and failing to have adequate procedures for identifying and correcting errors in a timely manner. In addition to the fine, the companies must pay restitution of interest to affected claimants. Both entities must pay combined restitution to affected claimants for interest due for late paid claims of approximately $915, 000 for calendar years 2001 and 2002. For prior years the companies must provide additional unpaid interest for claims processed from September 18, 1999 (the date the present text of Maine's prompt pay law took effect) to January 1, 2001. The companies will have until the end of January 2004 to calculate the additional interest due. The aggregate amount for the four years will be the largest award of restitution ever obtained for claimants by the Maine Bureau of Insurance. In addition to the claims payment issue, the consent agreement resolves a number of other violations. These include: complaint handling, company grievance procedures, records retention, failure to actively market individual health plan coverage, and member notification concerning plan cancellation. One of the most startling findings to emerge from the examination was the fact that CIGNA's own grievance review process overturned initial claim denials, when appealed, a significant percent of the time. The consent agreement requires that the companies file a plan of corrective action for the Superintendent's review and approval that addresses each violation of law listed in the consent agreement. The action plan is due to the Superintendent by December 31, 2003. The Superintendent singled out the grievance process as one area where the Bureau sought reforms. The Bureau of Insurance is part of the Department of Professional and Financial Regulation, which encourages sound ethical business practices through high quality, impartial and efficient regulation of insurers, financial institutions, creditors, investment providers, and numerous professions and occupations for the purpose of protecting the citizens of Maine. Consumers can reach the Bureau through its Web site at; by calling 800-300-5000 in-state; or by writing to Bureau of Insurance, 34 State House Station, Augusta, ME 04333. This information is reprinted with permission of the The Monument Newspaper Copyright 2003.


Revised 2004 Medicare Physician Fee Schedule and Extension of the Annual Participation Enrollment Period

It is my understanding that CMS has revised the Medicare Fee Schedule for 2004 and extended the time providers have to decide whether enroll with CMS as a participating provider. Doctors have until February 17, 2004 to consider the new fee schedule before making their 2004 participation decision. The new fee schedule incorporates increases passed by Congress and signed by the President into law on December 8, 2003. Because the law was signed so late in the 2003 calendar year, CMS is back peddling trying to incorporate the changes brought on by the law with the current calendar year. As a result, CMS has extended the time providers have to consider the new fees and whether they want to remain a participating provider or not. As a result Medicare contracted carriers have released the following physician advisory at the behest of the CMS: 1. Providers should stop and contemplate the rate increases authorized by the Medicare Prescription Drug, Improvement, and Modernization Act before making their 2004 Medicare participation decision. If doctors decide to maintain the same participation status in 2004 that they currently have now, they do not need to take any further action. 2. After reviewing the new rates, members should understand the extended timeframes for making their decision and the rules involving their 2004 payments while their decision is being processed, especially if they decide to change their participating status. 3. If members decide to change their participation status, they should be sure to complete the participation agreement that everyone should have received from their respective carrier and submit it to that carrier as soon as possible. The 2004 participation enrollment period has been extended and carriers will accept the agreements postmarked as late as February 17, 2004. For the complete listing of the new Medicare fees, go to MEMBERS ONLY section under INS. & MANAGED CAREE and then select MEDICARE:


Nation's Largest Insurers Meet with ACA To Improve Relations Between Insurance Industry and Chiropractic Profession

Continuing to build an infrastructure between the insurance industry and the chiropractic profession, the American Chiropractic Association (ACA) recently participated in the latest in a series of conferences with leaders of several major insurance groups. Known as the Claims Solutions Work Group (CSWG), the conference was held in Chicago, IL, and featured senior-level executives of the ACA, the National Association of Independent Insurers (NAII), Shelter Insurance, Farmers Insurance, Allstate, national and state BlueCross BlueShield, General Casualty Insurance, AAA, Erie Insurance Group, American Family Insurance and Metropolitan Life Insurance, among others. Hosted by NAII, the largest property/casualty insurance association, the meeting marked the sixth time ACA has participated in a CSWG conference since 1999. Expanding upon breakthroughs achieved from past CSWG meetings, the participants discussed chiropractic reimbursement issues, developed joint projects that will support a better relationship between insurers and doctors of chiropractic, and identified priorities for the coming year. Specific problematic billing codes were also discussed, including extra-spinal CMT, neuromuscular reeducation, testing and measurement codes, massage, hot packs, manual therapy (97140) and E/M codes with CMT. Many insurers agreed to review their practices and those of their business partners as they relate to these codes. ACA President Donald Krippendorf, DC, has noticed continued, dramatic improvement in the communication and cooperation between payers and doctors of chiropractic as a result of the CSWG conferences. "In four short years the participants of the Claims Solutions Work Group have constructed a bridge between insurers and chiropractors that did not previously exist. The ACA is proud to be a part of this most important program." According to Paula Pfankuch, a senior manager with BlueCross BlueShield of Illinois, the meeting "really turned out to be a great day." Pfankuch added that BlueCross BlueShield of Illinois is "on board" and plans to participate in the next Claims Solutions Work Group meeting in the Spring. The next in the series of CSWG conferences is scheduled for March 3, 2004, in conjunction with ACA's annual National Chiropractic Legislative Conference (NCLC) in Washington, DC. Source: American Chiropractic Association

President Bush signs most sweeping changes in Medicare's history

President Bush on Monday signed into law the most far-reaching changes in Medicare in nearly four decades.(H.R.1 an act to amend title XVIII of the Social Security Act to provide for a voluntary prescription drug benefit under the Medicare program and to strengthen and improve the Medicare program, and for other purposes) most sweeping changes to Medicare since its creation in 1965. Included in this sweeping legislation in Sec 651 is a provision for DEMONSTRATION OF COVERAGE OF CHIROPRACTIC SERVICES UNDER MEDICARE. To read Sec. 651 view page 436 of the link below.



When appealing a claim denial from an ERISA health plan, it is important to determine the extent of the plan's chiropractic benefits as well as who made the decision to deny the claim and why, said Karen L. Handorf, deputy associate solicitor in the Plan Benefit Security Division of the U.S. Department of Labor (DOL). All of this information is available to patients, and doctors acting as patient representatives, under new DOL regulations. Employers with ERISA health plans are also obligated under the new rules to follow specific steps in the appeals process. Handorf, whose DOL division is responsible for providing litigation and advisory legal services under ERISA, participated in an Oct. 24 teleconference on new ERISA-related court rulings and Labor Department regulations hosted by ACA for chiropractic attorneys and state association representatives. She told the group that, at present, individual doctors and their patients are better off going through a plan's appeal procedure to obtain benefits rather than filing a lawsuit. If you have to file a lawsuit in federal court, the plan's decision is usually reviewed under an "arbitrary and capricious" standard; you are limited to the evidence that was presented to the plan administrator, and you will not be able to obtain anything more than the benefits that were promised. States can regulate insured plans through their state insurance laws, and the courts are interpreting ERISA preemption language to allow for more expansive regulation of insured plans by the states. ERISA, the Employee Retirement Income Security Act, was passed in 1974 and intended to encourage large multi-state employers to provide pension, health care and other compensation to their employees by shielding them from various state laws governing pension and insurance laws and instead requiring compliance with one set of federal laws. The law, however, also made it difficult for individuals to get relief for denied claims or botched treatment. About 80 percent of workers not covered by a government-based health plan receive their health care through an ERISA-protected plan. In response, the DOL this year issued new claim appeal procedures effective for all health benefit plans subject to ERISA regulations. It includes a specific time frame for filing an appeal, spells out the rights of the plan participants and responsibilities of the plans, and requires the plan to indicate why and on what basis a claim was denied. Handorf told participants that the first course of action should be to obtain the health plan's "SPD" or summary plan description, which describes-in plain, understandable terms-what a beneficiary is entitled to and what his or her rights are under the plan. From this, doctors and patients can determine if the denial is based on limitations allowed in the SPD. "It all comes down to how a plan is written..." says Handorf. "I would think that most plans that provide chiropractic benefits would be pretty specific about it." If a claim is denied for reasons of medical necessity, doctors and patients have the right to know the identity of the reviewer (who should have appropriate training and experience in the specific health care field involved) and the reasons for the denial. Once this information is known, doctors should submit any additional evidence supporting their treatment decisions to the health plan to be included in the official administrative record. Attention to such details of the appeals process is essential; otherwise, evidence may not be admissible further down the line.


Superintendent of Insurance Gregory V. Serio, along with New York City Police Commissioner Raymond W. Kelly and Brooklyn District Attorney Charles J. Hynes announced on Sunday the arrest of 51 individuals as part of the takedown of a no-fault insurance fraud ring in New York City. The arrests are the first phase of "Operation Gateway," an investigation into a criminal organization that is taking advantage of New York’s no-fault laws by falsifying auto accidents. It is estimated that fraudulent no-fault insurance claims amount to tens of millions of dollars a year in New York State, and hundreds of millions of dollars nationwide. Based on the evidence in this case, the loss is in the tens of millions of dollars. "The elaborate scheme and sophistication of the criminals involved in the case dismantled today proves that criminals are aware of how to circumvent the current no-fault law and make a great deal of money by doing so," said Superintendent of Insurance Gregory V. Serio "The Governor, the Insurance Department and law enforcement agencies, like the New York Police Department and Brooklyn District Attorney’s office, are doing everything within the power of the current law to take these criminals off the street, but until there is legislative action we will continue to see criminals like these who steal tens of millions of dollars from the auto insurance system and cause auto insurance rates to increase for honest New York drivers." A typical no-fault auto insurance scam begins with "runners," or recruiters who arrange to send individuals supposedly injured in an accident to clinics for treatment. The runners obtain phony accident reports and recruit ‘victims’ to send to medical clinics, which are paid off to provide medical tests. Lawyers are also involved who file insurance claims, up to $50,00 per victim which is the maximum amount allowed under New York’s no-fault laws. The organization’s top leaders keep most of the money and paid off those involved. In this case, runners were paid up to $2,500 for every victim they could link to a fictitious accident. The Department participated in the weekend takedown where NYPD detectives posed as insurance company representatives, called them at home to inform them they had been awarded an insurance claim of up to $11,000 and to pick it up in person in Queens. When they arrived to pick up their claim money, they were arrested and charged with fraud. The Department was initially contacted by the New York City Police Department to assist in the investigation in December 2002 after the NYPD received a tip regarding a suspected fraud ring in New York City. Also assisting in the investigation were Liberty Mutual Insurance Company, Kemper Insurance Company, MetLife Insurance Company, Allstate Insurance Company, Progressive Insurance Company, Clarendon Insurance Company, Continental Insurance Company, The Robert Plan, Eagle Insurance Company, GEICO Insurance Company, The Hartford Insurance Company, State Farm Insurance Company, Lancer Insurance Company, the Motor Vehicle Accident Indemnification Corporation, Nationwide Insurance Company, New York Central Mutual Fire Insurance Company, Statewide Insurance Company and Travelers Insurance Company. New York is aggressive in its fight against insurance fraud. To report suspected incidents of insurance fraud call 1-888-FRAUD-NY (1-888-372-8369). It should be noted that an arrest is merely an accusation and that a defendant is presumed innocent until proven guilty.



The Centers for Medicare & Medicaid Services (CMS) announced today that it will implement a contingency plan to accept noncompliant electronic transactions after the October 16, 2003 compliance deadline. This plan will ensure continued processing of claims from thousands of providers who will not be able to meet the deadline and otherwise would have had their Medicare claims rejected. 'Implementing this contingency plan moves us toward the dual goals of achieving HIPAA compliance while not disrupting providers' cash flow and operations, so that beneficiaries can continue to get the health care services they need,' said CMS Administrator Tom Scully. CMS made the decision to implement its contingency plan after reviewing statistics showing unacceptably low numbers of compliant claims being submitted. 'Medicare is able to process HIPAA-compliant transactions,' said Tom Grissom, director of CMS' Center for Medicare Management, 'but we need to work with our trading partners to increase the percentage of claims in production.' The contingency plan permits CMS to continue to accept and process claims in the electronic formats now in use, giving providers additional time to complete the testing process. CMS will regularly reassess the readiness of its trading partners to determine how long the contingency plan will remain in effect. The authority to implement a contingency plan was provided by guidance issued by HHS on July 24. CMS recognized that transactions often require the participation of two covered entities and that non-compliance by one covered entity may put the second covered entity in a difficult position. The guidance stated that covered entities that make a good faith effort to comply with HIPAA transactions and code set standards may implement contingencies to maintain operations and cash flow. CMS announced its contingency plan on September 11, but at that time had not made a decision on whether the plan would be implemented. Today's announcement means the CMS plan will be implemented on October 16, 2003. 'We encourage other plans to assess the readiness of their trading partners and implement contingency plans if appropriate,' Grissom said.

New York State Chiropractic Association Leadership Meets with Oxford/Triad

The NYSCA officers and downstate board members met with Oxford representative Drs. James Dillard and Bartley Bryt and Triad officers, Drs. Agostino Villani and Santo Sampini during the NYSCA convention in Rye Brook, NY on September 19, 2003. The purpose of the meeting was to discuss NYSCA member issues with Triad handling of care plans over the past nine months. Much of member complaints focused on onerous paper work (first visit submission of care plans with 30 day extensions); down coding; lack of supportive care approval (even though Triad reports approval of this type of care); difficulty in treating the chronic pain patient and the lack of clinical information on care plans on which treatment authorizations are based. An additional issue that was addressed and immediately clarified was the PCP referral. It was explained that once the patient has obtained the PCP referral, providing they remain in the same plan, the patient does not need a new referral after the initial even with lapses or discharge from care. As far as the remaining issues are concerned, Triad reports changes to the forms to be implemented in the new year. They recommend visiting their website to view the provider manual for proper filing of forms as well as being able to download care plans to be filled out on your desktop. Your NYSCA leaders plan to continue discussions with Oxford to assist them in understanding chiropractic in the managed care environment. We will keep communications open with Triad as long as our members have issues. Your responsibility is to communicate your problems with us. We are particularly interested in supportive care denials. NYSCA - working for you - with you.