As previously reported, United Healthcare and its subsidiaries will require the GP modifier to be appended to any codes that are deemed “Always Therapy” codes according to CMS for dates of service on or after April 1, 2020.
As we have previously reported to you, Inovalon is a company that is collecting patient records to perform risk adjustment reviews on behalf of Horizon. Risk adjustment reviews are reports required by and provided to the government as dictated by the Patient Protection and Affordable Care Act (PPACA aka Obamacare). All carriers collect data for these reports and in the years these have been required we have not yet seen a negative consequence for any provider stemming from these record collections.
You may have seen articles recently announcing an agreement between Senate President Steve Sweeney and the NJEA on changes to the School Employee Health Benefits Program. There are many details not yet available regarding these changes but here is a breakdown of what we know at this point.
We had previously advised membership that Medicare had begun covering acupuncture in certain specified situations as of Jan. 21, 2020. Acupuncture is to be allowed for chronic low back pain for 12 visits with an additional eight if improvement is shown, with no more than 20 visits allowed annually.
After several delays, for dates of service on or after April 1, 2020, United Healthcare will require the GP modifier to be appended to any codes that are deemed "Always Therapy" codes according to CMS.
CMS announced on Tuesday that Medicare will cover acupuncture for chronic low back pain for dates of service on or after Jan. 21, 2020.
Winter Edition 2020 - Vol. 16 No. 1
Many members have reported receiving a letter, phone call or both from Inovalon on behalf of Horizon. Inovalon is a company that has performed what are called Risk Adjustment Reviews for various carriers over the years.
The 2020 Medicare fee schedule, deductible and premiums have been released.
By Susan K. Livio | NJ Advance Media for NJ.com, Oct 21, 1:30 PM
State regulators have denied a request from Horizon Blue Cross Blue Shield of New Jersey to team up with a national claims reviewer to scrutinize claims for chiropractic, physical therapy and acupuncture treatment next year, officials confirmed.
By Lindy Washburn, North Jersey Record, Oct. 17, 2019
A plan by the state’s largest health insurer that touched off fierce opposition from New Jersey chiropractors and others has been rejected by the state Department of Banking and Insurance. Horizon Blue Cross Blue Shield of New Jersey planned to give oversight of coverage for physical health services — chiropractic, physical therapy, occupational therapy and acupuncture — to a separate company, American Specialty Health Network, starting on Jan. 1. But Commissioner Marlene Caride rejected the proposed contract.
Fall Edition 2019 - Vol. 15 No. 4
As previously reported, United Healthcare had planned to require the GP modifier to be added to all "therapy codes" as of September 1, 2019. Per the United Healthcare September news bulletin, this policy will be "delayed to give care providers more time to adjust to changes in the submission of 'Always Therapy' procedure codes to include the CMS required therapy modifiers."
Lindy Washburn, North Jersey RecordPublished 5:30 a.m. ET Sept. 9, 2019
A federal judge in Pennsylvania has approved $20 million in payments to settle two class-action lawsuits brought by chiropractors against a health insurer and American Specialty Health, the national company chosen by Horizon Blue Cross Blue Shield of New Jersey to manage its members’ benefits for chiropractic care and other physical health benefits starting next year.
Lilo H. Stainton | September 9, 2019
Horizon Blue Cross Blue Shield and American Specialty Health Group allege that various alternative healthcare providers have spread false and defamatory information against them
By Lindy Washburn, North Jersey Record, Aug. 22, 2019
The state’s largest insurer plans to shift oversight of its members' benefits for chiropractic care, physical therapy, occupational therapy and acupuncture to a separate company next year, in a plan that has drawn intense opposition from chiropractors and other medical providers.
By Lilo H. Stainton | AUGUST 13, 2019
If approved by the state, American Specialty Health Network would oversee Horizon’s acupuncture, chiropractic services, physical therapy and occupational therapy claims
By Susan K. Livio | NJ Advance Media for NJ.com
Armed with data that says New Jerseyans are among the most frequent users of chiropractic care and physical therapy in the nation, the state’s largest health insurance company says it intends to team up with a national claims reviewer to scrutinize patient bills in the coming year.
Easily email your local representatives in Trenton plus other key lawmakers to encourage them to ask DOBI not to approve a partnership between Horizon BCBS and ASH!
You may have or will soon be receiving a letter from Horizon announcing that they have entered into an agreement with American Specialty Health Networks (ASH). ASH will be providing network management services for Horizon beginning January 1, 2020.
New Jersey has passed state laws mandating that bills for Personal Injury Protection (PIP) claims and Workers' Compensation claims must be billed electronically.
Summer Edition 2019 - Vol. 15 No. 3
The minimum wage for employers with six or more employees in New Jersey has been raised to $10.00 per hour as of July 1, 2019. The rate will rise $1.00 to $11.00 per hour on January 1, 2020 and then an additional $1.00 each year until reaching $15.00 in 2024.
United Healthcare has delayed the requirement to append the GP modifier to any codes that are deemed "Always Therapy" codes, according to CMS, until September 1, 2019.
Nominations Now Open for ANJC Lifetime Achievement Award and Chiropractor of the Year!
Beginning July 1, 2019 United Healthcare will require the GP modifier to be appended to any codes that are deemed "Always Therapy" codes according to CMS.
Postcards regarding the $11.75 million settlement of the CIGNA-ASHN class action lawsuit have begun reaching class members. As such, the ANJC wants to provide what you need to know.
In response to more members seeking recourse for a wide variety of issues with insurance carriers and their programs, we have put together a brief webinar. The webinar walks you through where to find and how to file a complaint to the New Jersey Department of Banking and Insurance, otherwise known as DOBI.
Spring Edition 2019 - Vol. 15 No. 2
Optum has agreed to lease its network to Zelis (formerly Stratose). Zelis is a “health care savings company” which is also sometimes known as a silent PPO company. What this means is that if you are in-network with Optum but out of network with a number of companies Zelis works with, then you will be paid at the Optum contracted rates rather than the out of network rate for the carrier under contract with Zelis.
Recording of webinar presented on Monday Feb. 25, 2019.
Review of the latest updates regarding Aetna, NIA and the SHBP/SEHBP Medicare Advantage Plans.
As previously reported, Aetna will be implementing a new pre-authorization program being managed by National Imaging Associates (NIA) beginning January 1st. The process will be required for in-network providers on fully funded policies only. For claims submitted on or after January 1st pre-authorization will be required in order for payment to be issued.
On Oct. 2, 2018, we advised that many members had received denials from Aetna for lack of pre-authorization of care. We immediately approached Aetna regarding this as the new pre-authorization program is not set to begin here in New Jersey until Jan. 1, 2019
As previously reported, Aetna’s contract with Triad/eviCore is expiring on Dec. 31, 2018. A vendor called National Imaging Associates (NIA) will be managing a new pre-authorization program immediately following the Triad contract expiration, starting Jan. 1, 2019.
Late Friday we were notified by Aetna of revised plan designs for the SHBP/SEHBP Medicare Advantage plans for 2019.
We have previously reported that all Medicare eligible retirees under the SEHBP (teachers) who are enrolled in traditional Medicare with either the NJ Direct 10 or NJ Direct 15 plans will be automatically enrolled into new Aetna Medicare Advantage plans. It has come to our attention that additionally, any retired SHBP (police, fireman, etc.) employees who had been enrolled in the Horizon Medicare Advantage NJ Direct 10 or 15 will also be moved to new Aetna Medicare Advantage plans.
Additional details have become available regarding changes to the School Employee Health Benefits Program (SEHBP). First, the changes previously described were approved by the School Employee Health Benefits Commission and are hence, official. Both the new plan option and the retiree changes will be effective as of January 1, 2019.
Many members have received a letter from Aetna regarding a new pre-authorization process coming January 1, 2019. Aetna’s contract with Triad/eviCore is expiring on December 31, 2018. A vendor called National Imaging Associates (NIA) will be managing this new pre-authorization program immediately following the Triad contract expiration. The process will apply to all physical medicine procedure codes regardless of what type of provider performs them whether it be a DC, PT or MD. The pre-authorization program will be applied to in-network providers on fully funded plans only.
Yesterday, following an agreement between Gov. Murphy and the New Jersey Education Association, the School Employee Health Benefits Program’s (SEHBP) Plan Design Committee passed several resolutions enacting reforms to reduce costs under the plan. The SEHBP covers all employees of K-12 schools and community colleges that opt into the state program.
As previously reported, the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act requires a disclosure form to be signed by patients beginning August 29, 2018. We have updated our interim sample form (to be replaced by official form once released by the Board of Chiropractic Examiners) to include sections for both in and out of network providers/patients.
As you are aware, on June 1, 2018, Governor Murphy signed into law the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act. The main components of the bill were designed to protect patients from unexpected out-of-network bills for providers operating at in-network hospitals or other healthcare facilities. There are however several new disclosure requirements that apply to all out-of-network providers, including chiropractic physicians.
The ANJC today received the Appellate Division's decision in the State Health Benefit Plan $35 cap on out-of-network chiropractic reimbursement appeal.
While no legislation to repeal or amend Obamacare has become law, we do have a bill passed by the U.S. House of Representatives and a draft of a bill from the U.S. Senate. Here we examine some of the major themes from the most recent offerings of the two chambers of Congress.
CMS has released an updated Advanced Beneficiary Notice of Non-coverage (ABN) form (Form CMS-R-131). There are no substantive changes to the form or its usage. However, the updated form has added language informing beneficiaries of their rights to CMS nondiscrimination practices and how to request the ABN in an alternative format if needed. The new form also includes the updated expiration date of the form which is 03/2020.
As previously advised, as of April 17th 2017 the New Jersey Department of Banking and Insurance (DOBI) mandates a uniform appeal process using specific forms for pre- and post-service appeals created and provided by the NJ DOBI. Shortly after implementation, it came to our attention that nearly all carriers made changes to their Decision Point Review (DPR) plans following this change. Certain changes found are clearly detrimental to medical providers treating PIP patients and most importantly, to the patients themselves.
On Tuesday, May 09, 2017, the ANJC’s General Counsel Jeffrey Randolph engaged in oral arguments with a Deputy Attorney General of the New Jersey Attorney General’s Office before the NJ Appellate Court in the ANJC vs. the State Health Benefits Commission et al. case.
As previously advised, the NJDOBI is instituting a uniform appeals process for PIP claims. This new uniform appeal process will be in effect as of April 17, 2017. Jeffrey Randolph Esq., General Counsel to the ANJC, has created a webinar explaining the changes and new process.
On Oct. 17, 2016, the New Jersey Department of Banking and Insurance (DOBI) published in the N.J. Register amendments to the PIP regulations implementing a new, mandatory appeal process for PIP claims to take effect April 17th.
The 2017 Medicare fee schedule has been released.
There are significant changes coming to the Medicare system of reimbursement beginning in 2017. This comes in the form of what is called the Quality Payment Program.
For the sixth consecutive year, ANJC is making available six $1,000 scholarships, including the second annual “Sigmund Miller Spirit of Chiropractic Award,” for chiropractic students who reside and have a home-base in NJ, and plan to return to NJ to practice.
Since our last update on the State Health Benefits Plan we have obtained the resolutions passed by the SHBP Plan Design Committee at their 8/29/16 meeting via OPRA request. Three of the seven resolutions have possible bearing on ANJC members.
There are changes to the ICD-10 diagnosis codes going into effect October 1st, 2016. CMS will be requiring codes to be submitted to the greatest available specificity beginning on October 1st. Also, there have been a number of codes added and deleted from the ICD-10 code set.