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ACA- New Jersey

"A special thanks to Dr. Stiso, the ACA and Pat Jackson of the ACA for their Intervention with the blatant discrimination and profiling of NJ Chiropractors, by Horizon BC/BSNJ."

-R. Calio DC

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May 12, 2003

Donald Bryan, Director, Division of Insurance

State of New Jersey Department of Banking and Insurance

PO Box 325

Trenton, NJ 08625-0325

Dear Mr. Bryan,

Let me begin by thanking you for taking the time to meet with Dr. Frank Stiso, ACA Delegate, and myself this past April 22nd regarding what we believe to be unfair practices by Horizon Blue Cross Blue Shield of New Jersey. We are concerned that the administration of Horizon's plans is unfair and inconsistent.

The reason I am writing to you today, and the reason I met with you in April is to request your assistance as direct remedies between ACA and Horizon have failed. Horizon has yet to establish a forum to deal with our concerns in a responsible way. There appears to be a resistance to Horizon reviewing chiropractic literature, which indicates chiropractic care, is less costly for neuromusculoskeletal conditions.

Our concerns are disturbing and broad and include a limit on the scope of practice of doctors of chiropractic by not paying for Evaluation and Management codes or Physical Therapy codes. In denying coverage for these codes, they also do not allow practitioners to balance bill their patients, so the doctor receives no reimbursement for these very important services. Horizon does pay other providers for these same services. In addition, Horizon reimburses doctors of chiropractic at a non-physician level with no regard for parity with other providers who perform like services.

We are asking for the intervention of the New Jersey Department of Banking and Insurance to obtain clarity of Horizon's practices and their intentions regarding appropriate change. If Horizon refuses to comply with the Department's request, we may file a formal complaint against Horizon and

Ask that the Department of Banking and Insurance conduct a Market Conduct Exam.

Please let me know if you have any questions regarding this matter or if I can be a source of further assistance or information, please contact me at 800-986-4636 x222. Thank you for your personal involvement on behalf of the insuring public.

Sincerely,

Patricia S. Jackson, Vice President, Office of Professional Development and Research

 

 
ACA meets with Don Bryan and Gail Simon, Directors at the New Jersey Department of Banking and Insurance 4/23/03

Dear Colleague:

Today, Pat Jackson from the ACA and I met with the New Jersey DOBI concerning Horizon BCBSNJ. We were told for years by Horizon that the DOBI did not have jurisdiction over them as they were a Hospital Service Corporation. That statement is false.

We discussed Horizon's refusal to change, what we feel, are discriminatory reimbursement tactics that target the chiropractic profession. Horizon doesn't have difficulty in reimbursing other physicians for similar services. They reimburse non-physicians, (PTs) for procedures that they deny to us, and we are defined as physicians within New Jersey statutes.

The DOBI was "floored" when we explained that Horizon denies reimbursement for E/M codes, while allowing them to other physicians. To add insult to injury, Horizon demands the results of a re-examination/evaluation in their review policy during utilization review, but refuse reimbursement for the examination. The DOBI couldn't understand Horizon's position as a healthcare carrier, as the DOBI allows these same procedures within the PIP laws. They asked us, how & why should there be a difference between PIP & Horizon, especially while other carriers are reimbursing DCs for these procedures.

The Blues will now be called in by the DOBI for an informal hearing. If they still refuse to change their chiropractic reimbursement policies, the ACA will take more drastic measures and that will probably be to file a formal complaint.

I will keep you informed as to progress.

Frank A. Stiso, D.C.

New Jersey ACA Delegate

 

NJ DOBI Meeting April 22, 2003

Dr. Frank Stiso, ACA State Delegate, and I met with officials from the New Jersey Department of Banking and Insurance on April 22, 2003. The purpose of the meeting was to discuss what we believe are unfair claim practices toward doctors of chiropractic and to determine the regulatory over-site the DOBI has over Horizon Blues plan. We met with Donald Bryon, Director, Division of Insurance and Gale Simon, Assistant Commissioner Life and Health Division.

Our strategy was to relay our general concerns and discuss the many attempts we have made to remedy the situation directly with Horizon to no avail. As a last resort, we want to engage the DOBI to intervene on behalf of state DCs, the public and ACA to get answers and accountability from Horizon.

The Department indicated they have a low tolerance level with Horizon tactics and have had years of experience in dealing with them on various concerns. They do have regulatory scope over Horizon and also licensing authority. They will ultimately approve if Horizon goes public or not. They do not have authority over the ERISA plans Horizon administers, which is understood.

Our concerns about unfair policy administration (caps, limits, limitation on scope of practice, different treatment than others performing same services, reimbursement parity etc.) were heard. We also planted a seed about the cost-effectiveness of the DC model of care vs. the traditional model that's not working to control costs and encouraged them to approve insurance plans that offered patient choice and options for holistic care. Recent research studies were left with them that clearly bring forward improved costs, outcomes and patient satisfaction when using chiropractic care for NMS conditions.

The DOBI officials were not surprised, but were dismayed, at much of the information we relayed about unfair practices and agreed they can and should have a role in questioning the Blues.

The plan is for ACA to send a follow up letter to the DOBI so they can do a direct inquiry with the Blues. If Horizon refuses to cooperate, it was recommended we file a formal complaint to request an investigation of Horizons practices. This is compelling as the DOBI suggested the strategy to bear pressure on the Blues and is cooperating fully with the ACA to address our concerns.

Mr. Bryan and Ms. Simon felt we were reasonable in our approach and expectations. Dr. Stiso explained his role within Horizon's Medical Policy Committee and expertly provided clinical evidence of wrong-doing. As a liaison to the Forum, he also offered to be the point person for keeping the profession updated and to bring forward any further concerns. Mr. Bryan also indicated he will ask for Dr. Stisos help in communicating with state DCs and may bring Pat into discussions on the PIP reform initiative which is still pending. The Department also answered a technical question on a PIP compliance issue on retrospective review cut offs and indicated where insurers are responsible for adequate notice to providers.

The meeting went very well. I will draft a letter to Mr. Bryan for his use in intervening with Horizon but suspect we may ultimately need to file a formal complaint as Horizon has ignored congenial problem solving approaches in the past. Bringing in the agency that regulates Horizon and has the power to approve or not approve their move to a public entity will undoubtedly get Horizon's attention that reiterate that we are serious and will not go away until their practices are changed.

Pat Jackson, ACA VP Professional Development and Research

 

 

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