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ACA Files Class Action Lawsuit Challenging ASHN's, CIGNA's Improper Practices

Arlington, Va.--The American Chiropractic Association (ACA) has filed a class action lawsuit against American Specialty Health Inc. and American Specialty Health Networks Inc. (collectively, "ASHN"), and CIGNA Corporation and Connecticut General Life Insurance Company (collectively, "CIGNA"). The litigation alleges a litany of problems with the defendants, including arbitrary reductions of care, lack of communication to providers and patients resulting in coverage and payment errors, and interference with doctors' duty to exercise professional clinical judgment in managing patients' treatment plans.

Filed on Dec. 28, 2012, ACA's litigation--which is being handled by the law firm Pomerantz Grossman Hufford Dahlstrom & Gross LLP--represents a nationwide class of health care providers and subscribers who were subjected to ASHN and CIGNA's improper coverage and reimbursement practices.

Furthermore, CIGNA allegedly failed to comply with terms and conditions of its plan to afford its subscribers or their health care providers an opportunity to obtain a "full and fair review" of denied or reduced reimbursement, and to make appropriate and non-misleading disclosures to subscribers or their health care providers--an alleged violation of the Employee Retirement Income Security Act of 1974 (ERISA), the federal law governing private employee benefit plans. Additionally, the litigation outlines various allegations, including:
  • Use of false and misleading Explanations of Benefits relating to chiropractic claims (required under ERISA for informing subscribers of how their claims have been processed), which interferes with the doctor-patient relationship
  • Manipulating charge and payment data, allowing ASHN and CIGNA to pass on excessive costs to subscribers, while distorting the amounts providers actually receive in benefit payments
  • ASHN's restrictions of care via the pre-authorization process and provider contract provisions that prevent patients from having access to the full breadth of their benefits and in contradiction to their certificates of coverage--a violation of ERISA
  • ASHN and CIGNA's imposition of excessive co-pay requirements on subscribers, another ERISA violation
  • CIGNA's improper prevention of doctors of chiropractic (DCs) from providing services that fall within their scope of practice, in violation of state provider non-discrimination laws
  • ASHN and CIGNA's violation of various state prompt payment laws
ACA's suit requests the court to award injunctive, declaratory and other equitable relief to ensure ASHN and CIGNA's compliance with ERISA as well as other state and federal laws and regulations.

"ACA was compelled to take this action against ASHN and CIGNA because their egregious practices are undermining patient care and doctor-patient relationships. DCs feel they have to choose between acting in the best interest of the patient, and adhering to the requirements imposed by ASHN and payers they work with," said ACA President Keith Overland, DC. "Since 2002 we have worked to try and improve these issues. It is now time for action and we will not rest until patients across the nation receive all the care they need and have paid for through their insurance premiums."

Providers who believe they and/or their patients have been affected by ASHN and/or CIGNA's improper practices can visit the Chiropractic Networks Action Center where they will find instructions and forms that can be used to submit a complaint to ACA.

The American Chiropractic Association (ACA), based in Arlington, Va., is the largest professional association in the United States representing doctors of chiropractic. ACA promotes the highest standards of patient care and ethics, and supports research that contributes to the health and well-being of millions of chiropractic patients. Visit www.acatoday.org.

 

NGS Medicare Announces Important Updates Effective January 1, 2013

NGS Medicare has released several updates regarding changes that took effect on January 1, 2013. The principle highlights include the following:
  • The new fee schedule will be effective as of January 1, 2013, but is not published on the NGS web site at this time. For bookkeeping purposes, you may want to consider holding 2013 Medicare billings until later in the month. Check the website for updates.
  • Participation in PQRS is no longer optional as of January 1, 2013. Providers who do not report quality measures beginning January 1, 2013 will see a 1.5% fee reduction penalty starting in 2015.
  • EHR incentives are also still in effect with financial incentives available to those who qualify.
For more details on this release, please see the article below. Additionally, the New York Chiropractic College will be offering a NY Medicare educational program on January 10, 2013 at all locations. Among the topics to be covered are the Physician Quality Reporting System (PQRS), along with other Medicare procedures.

As always, the NYSCA will continue to send updates as we receive them.

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President Obama Signs the American Taxpayer Relief Act of 2012
--New Law Includes Physician Update Fix through December 2013--

On Wednesday, January 2, 2013, President Obama signed into law the American Taxpayer Relief Act of 2012. This new law prevents a scheduled payment cut for physicians and other practitioners who treat Medicare patients from taking effect on January 1, 2013. The new law provides for a zero percent update for such services through December 31, 2013. This provision guarantees seniors have continued access to their doctors by fixing the Sustainable Growth Rate (SGR) through the end of 2013...

Section 601 – Medicare Physician Payment Update – As indicated above, the new law provides for a zero percent update for claims with dates of service on or after January 1, 2013, through December 31, 2013. The Centers for Medicare & Medicaid Services (CMS) is currently revising the 2013 Medicare Physician Fee Schedule (MPFS) to reflect the new law’s requirements as well as technical corrections identified since publication of the final rule in November. For your information, the 2013 conversion factor is $34.0230.

In order to allow sufficient time to develop, test, and implement the revised MPFS, Medicare claims administration contractors may hold MPFS claims with January 2013 dates of service for up to 10 business days (i.e., through January 15, 2013). We expect these claims to be released into processing no later than January 16, 2013. The claim hold should have minimal impact on physician/practitioner cash flow because, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 for paper claims) after the date of receipt. Claims with dates of service prior to January 1, 2013, are unaffected. Medicare claims administration contractors will be posting the MPFS payment rates on their websites no later than January 23, 2013.

The 2013 Annual Participation Enrollment Program allowed eligible physicians, practitioners, and suppliers an opportunity to change their participation status by December 31, 2012. Given the new legislation, CMS is extending the 2013 annual participation enrollment period through February 15, 2013. Therefore, participation elections and withdrawals must be post-marked on and before February 15, 2013. The effective date for any participation status changes elected by providers during the extension remains January 1, 2013. (continued at http://bit.ly/2013MedicareUpdates)

 

One-Year Postponement in Medicare Reimbursement Cuts Included in Fiscal Cliff Package

The fiscal cliff legislation expected to be signed by the president today, contains a one-year delay in a scheduled cut in reimbursement for Medicare providers, including doctors of chiropractic.

The legislation will block a 27 percent payment cut to Medicare physicians that was due to start January 1st and keep rates frozen at current levels for the rest of this calendar year. Medicare providers were also set to face an additional two percent cut due to further budget tightening provisions, known as "sequestration," but that cut has also been suspended to give Congress time to find alternatives to this across-the-board cut in federal programs.

Once the fiscal cliff legislation has been signed, Medicare claims contractors will adjust their 2013 fee schedules accordingly; many have already removed the reduced 2013 fees from their web site so this adjustment can be made.  Please check your contractor's web site periodically for these new fees. Until the new fees are posted, the ACA recommends using the 2012 fee schedule.

 

District 3 Meeting - HOW DYNAMIC MOVEMENT GUIDES THE DECISIONS IN YOUR PRACTICE

 

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Several Long Awaited Proposed Health Reform Regulations Released

Several long awaited proposed regulations that govern implementation of the Patient Protection and Affordable Care Act (PPACA) provisions were released by the Department of Health and Human Services (HHS) on Tuesday. These regulations are intended to provide detailed guidance regarding implementation of the 2010 law. Of special note--starting in Jan. 2014--it will be illegal for an insurer to discriminate due to pre-existing conditions in denying coverage. It is estimated that this one provision will provide insurance options for some 129 million Americans. In addition to the pre-existing conditions exclusion, insurers will not be able to discriminate based upon gender, occupation, claims history or health status for the purpose of raising premiums.

Additional Standards were also laid out in this week's proposed rule that relate to issuers' determinations of essential health benefits and their value. PPACA requires payers in the individual/small group markets to include within their plans core essential benefits. ACA is following this development closely and is active nationally on behalf of the profession. Be sure to look for ACA comments on these proposed rules in future editions of Week in Review. If you haven't yet decided to contribute to CHAMP, consider these national proposals and how they will affect you. Follow health care reform here.

 

Chairman Beloten Announces New Medical Treatment Guidelines for Workers’ Compensation

After continued conversations and meetings with the New York State Workers' Compensation Board, we are now able to confirm updates to the Medical Treatment Guidelines.

Effective February 1, 2013, regulatory changes will be made to the Medical Treatment Guidelines [MTGs] allowing for, among other things, maintenance care for chronic back and neck pain.  This is exciting news indeed!

Regulatory modifications to the MTGs include the following:
  • The new Carpal Tunnel Syndrome MTGs have formally been adopted. 
  • A new maintenance care program has also been adopted, allowing up to 10 visits per year for chronic pain for patients who have reached maximum medical improvement (MMI) and have a permanent disability. 
  • Variance Request transmission requirements are being clarified and simplified in order to reduce the number of technical violation rejections. Details regarding these changes will be released as they become available. 
  • Carriers are now permitted to grant a portion of a variance request. Providers and patients will have the right to request a review of any denied portion of the request. This new allowance provides an opportunity for providers and carriers to reach a compromise, resulting in a reduction in unnecessary litigation due to complete denials. 
It has been noted that, by far, the majority of variance requests (nearly 80%) submitted by providers have been for maintenance care for patients with chronic pain. The Medical Advisory Committee (MAC) continues to develop a chronic pain MTG. In the meantime, the MAC has agreed that some maintenance care (including chiropractic, physical therapy, and occupational therapy) should be available to patients with chronic pain who have received benefit from such treatment in the past. 

Accordingly, the revised MTGs will allow for up to 10 visits for maintenance care per year for patients who have reached maximum medical improvement (MMI) and have a permanent disability. These guidelines will apply to all claims effective February 1, 2013, regardless of the date of accident or the date of disablement.

Additional clarification is expected regarding the definition of “10 visits” (i.e. multiple body sites, CPT codes, and multiple provider types).  However, this is a move in the right direction and is a welcome change to the way workers’ compensation claims are currently administrated.

It is clear how beneficial these changes will be for injured workers and their providers:  The need for variance requests will be minimized or even eliminated for many patients; Employed patients will not have to lose time from work to attend hearings on denied requests; Recurrences of symptoms and exacerbations will be minimized, resulting in a better quality of life for our patients.

We anticipate that the Workers’ Compensation Board will continue to have open dialogue with the NYSCA and other vested organizations as we work together to serve the best interests of our patients and providers.

For more information, please see the official website of the New York State Workers Compensation Board:  http://www.wcb.ny.gov/content/main/SubjectNos/sn046_497.jsp

 

NYCC’s 2012 Fall Classes welcomed 208 new students

The NYCC Admissions Department welcomed 208 new students in its September classes: 122 students representing 23 states, Puerto Rico, Canada and South Korea in the chiropractic program, 32 in the acupuncture master’s programs, 29 in the on-line Master of Science in Applied Clinical Nutrition (MSACN) program, and 25 in its on-line Master of Science in Human Anatomy & Physiology Instruction (MSHAPI) program.

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National Government Services Upcoming Webinars on Chiropractic Services

National Government Services Upcoming Webinars on Chiropractic Services

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NYCC President Sadly Announces Passing of Faculty Member, Dr. Lillian Ford

 

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The New York Times Prints ACA's Letter to the Editor

On Sept. 3, The New York Times printed "Too Young to Have a Stroke? Think Again," about the risk of stroke among younger people, which stated that "Other activities that can cause a carotid tear are those that involve sudden neck jerks, including scuba diving, golf and tennis, as well as chiropractic manipulation and bending the head sharply back (the so-called beauty parlor stroke)." ACA President Keith Overland, DC, quickly responded with a letter to the editor that was printed on page 4 of the Science Times section of the Sept. 11 edition. Dr. Overland's response highlighted research published in the medical journal Spine, which concluded that the risk of vertebrobasilar artery stroke associated with a visit to a chiropractic physician is no different than the risk of stroke following a visit to a primary care physician, and that any observed association between stroke and cervical manipulation or primary care visits is most likely linked to patients with undiagnosed vertebral artery dissections seeking care for neck pain or headaches prior to their strokes.

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ACA to Court: N.M. Chiropractic Physicians Should Have Right to Self-Determination

The American Chiropractic Association (ACA) today filed an amicus curiae (friend of the court) brief in the New Mexico Court of Appeals, supporting the expertise of chiropractic physicians in that state and their right to self-determination.
 
ACA was compelled to file the brief after the International Chiropractors Association (ICA) joined forces with the New Mexico Board of Pharmacy and the New Mexico Medical Board in a December 2011 memorandum to the court, requesting a halt to efforts by the New Mexico Board of Chiropractic Examiners to create an advanced practice training and certification program for chiropractic physicians.
  
In making its argument in favor of allowing New Mexico chiropractic physicians to chart their own course in this matter, ACA's brief informs the court about the extensive educational background and training that chiropractic physicians receive today from accredited U.S. chiropractic colleges.
 
The brief also points out that ACA is the nation's largest and preeminent chiropractic professional association, and that its long-established policy has been to recognize that local doctors are best equipped to determine matters of scope.
 
"It is ACA's opinion that the New Mexico Board of Chiropractic Examiners should be given the same respect as other state boards and allowed to determine what is best for chiropractic physicians and patients in that state. We object in particular to actions by the ICA, as well as the state's pharmacy and medical boards, to interfere with the will of chiropractic physicians in New Mexico and the needs of their patients," said ACA President Keith Overland, DC.
 
It is uncertain at this time when the court will make its final ruling on the issue.

For more information, visit www.acatoday.org/NMbrief.












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New York Chiropractic College makes Honor Roll: Chronicle of Higher Education’s “Great Colleges to Work For”

Seneca Falls, NY: New York Chiropractic College employees know the College is a great place to work, and the Chronicle of Higher Education agrees! For the fourth year running NYCC earned a place on the Chronicle’s roll of “Great Colleges to Work For” alongside such notables as Duke University, University of Michigan and Notre Dame. Qualifying marks in more than four categories merited placement on the Chronicle’s select “Honor Roll” for the third year in a row. NYCC excelled in ten of the eleven available assessment categories - adding collaborative governance, teaching environment and senior leadership to last year’s seven winning classifications.

The program - nowone of the largest and most respected workplace-recognition programs in the country - distinguishes colleges for best practices and policies. After reviewing 46,946 surveys submitted by administrators, faculty members, and professional support staff members from 294 participating institutions, only 42 make it to the Honor Roll.

“To earn a place on the Chronicle’s select ‘Honor Roll’ for three consecutive years is truly an outstanding distinction! Students unquestionably benefit whenever quality instruction is delivered by satisfied faculty members and a customer-oriented staff,” said NYCC President Dr. Frank J. Nicchi.

More about NYCC and its graduate programs is available at www.nycc.edu





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Physiotherapists In The United Kingdom Gain New Power

This past month in the United Kingdom, physical therapists gained the right to prescribe medications independently.

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Performing Independent Chiropractic Examinations (ICEs)

There are a number of considerations of which you should be aware when performing independent chiropractic examinations (ICE):

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Multidisciplinary Practices

The health care professions constantly evolve. A variety of forces, sometimes in competition with one another, continue to shape and reshape the methods, procedures and the manner in which health care is provided to the public.

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Combating Fraud and Abuse in Medicare & Medicaid

As Medicare Contracted Advisory Committee Representative for NY, Dr. Lupinacci and I have been receiving many complaints regarding Medicare. As CAC reps, we work closely on these issues with the ACA. We also get many questions as to what we are doing to stop some of the unfair treatment we receive in Medicare. Dealing with CMS and the rules and regulations governing Medicare is a national issue, we wanted to share a communication from ACA with you:

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Doctors of Chiropractic Answer London's Call

With a little more than 24 hours until the opening ceremony of the London Olympic Games, it's worth remembering that in 1979, track and field star Dwight Stones broke barriers and thrust chiropractic care into the Olympic spotlight in an interview on national TV, where he spoke about the important work being done by Leroy Perry, DC.

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Dr. Jessica Grandal, wife of Dr. Alan Friedman Member District 7

 

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Big Win in Texas

The District Court of Travis County, 250 Judicial District withdrew its opinion and judgment dated April 5, 2012, and substitute the following in its place. The motion for rehearing filed by appellee Texas Medical Association is denied.

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Supreme Court Upholds Health Reform Law

ACA Will Continue to Fight for Patient Access to Chiropractic as Law is Fully Implemented 

Arlington, Va.- On June 28, 2012, the U.S. Supreme Court, in a controversial 5 to 4 decision, declared the Patient Protection and Affordable Care Act (PPACA) to be constitutional, including the much disputed "individual mandate" provision which requires individuals to purchase health insurance coverage. According to the American Chiropractic Association (ACA), the long-awaited court decision removes legal obstacles to the full implementation of the law on a timeline very close to what was planned when PPACA was signed into law in March 2010.



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