ACA meets with Don Bryan and Gail Simon, Directors at the New Jersey Department of Banking
and Insurance 4/23/03
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
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
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
Pat Jackson, ACA VP Professional Development and Research