If you participate with UnitedHealthcare / Optum you may have received notice of the change in the aforementioned prior authorization program.  Based upon the volume of calls, texts, and emails received by the NYSCA Insurance Committee (NIC), there has been several interpretations of the information published by UHC. For more information please access the following link:

UnitedHealthcare Updates

The 2025 Medicare Fee Schedule has been posted to the NGS Medicare website.

On November 1, 2024, the Board issued a reminder that it will require health care providers to contract with an electronic submission partner to submit the CMS-1500 universal medical billing form electronically on their behalf beginning August 1, 2025.

All Medicare providers and suppliers, including pharmacies, must not bill Medicare beneficiaries in the Qualified Medicare Beneficiary (QMB) eligibility group for Medicare Part A or Part B cost-sharing. This includes Medicare Part A and Part B deductibles, coinsurance, and copayments.

Read More: MLN Matters Fact Sheet October 2024

Mergers. Acquisitions. Affiliations. Increasingly common and complex. These relationships may have no bearing or influence on our practice and ability to provide high quality care to our patients, while others can have a profound impact. A current affiliation awaiting approval from New York State involves CDPHP and Lifetime Healthcare.

Starting today 11/18/2024, healthcare providers won’t have access to beneficiary eligibility information on the NGS Medicare interactive voice response (IVR) system. This includes all beneficiary eligibility information that was obtained under Option 1, Eligibility. The IVR will continue to offer the other non-eligibility transactions.

Beginning Jan. 1, 2025, the $15 copayment for the EmblemHealth-GHl portion of the Senior Care Plan will resume. Senior Care members will be required to pay a $15 copay each time they use the health services listed below. Copays are limited to one copay per provider per date of service.

UnitedHealthcare's Prior Authorization requirements for certain Medicare Advantage members (including UHC and AARP) are now in effect.  For more information, and to join us for a lunch and learn next week, please visit the UnitedHealthcare page in the members' only section of our website:

UnitedHealthcare

Every year there are updates to the ICD-10 codes. Listed below please find the codes most relevant to the Chiropractic profession per the cms.gov website. These changes take effect 10/1/2024. 

Effective August 29, 2024, Humana is requiring prior authorization of certain Medicare Advantage members for chiropractic manipulative therapy rendered on or after August 29, 2024. The NYSCA Insurance Committee (NIC) reached out to Humana over the past week to ascertain whether prior authorization was required for Humana Medicare Advantage members in New York.

The NYSCA continues to communicate with Optum regarding the implementation of the new prior authorization program for AARP and UnitedHealthcare's Medicare Advantage members. We understand many of you have been attempting to determine the impact of this requirement on your practice and the patients you serve.  

On Thursday August 1st many of you received UnitedHealthcare's Provider News email.  That edition of Provider News included a section titled 'Outpatient therapy and chiropractic prior authorization required starting Sept. 1'.  Due to the lack of clarity in that email, the NIC reached out to several members of Optum's team Thursday morning and afternoon to obtain more specific information about the new requirement.

As many of you have been aware, the NYSCA has been in communication with both Highmark and the NYS Department of Financial Services regarding of our member's concerns, including Highmark's implementation of a prior authorization program.  Please join your fellow NYSCA members on Monday, April 29th, 8pm for an open discussion regarding our current understanding of the Highmark Prior Authorization program.

As noted in our previous communication, Highmark BCBS of Western NY and Northeastern NY is implementing a prior authorization program for certain services rendered by DCs, PTs, OTs and home care providers.

As previously reported, Highmark is planning to implement a prior authorization program for chiropractic care, physical and occupational therapy, and home health care effective on April May 1, 2024.   Highmark recently updated their provider news to announce "For Highmark Blue Cross Blue Shield members in commercial plans, providers will need to request authorization for outpatient physical medicine and home health services, effective April May 1, 2024."

According to the 2024 Medicare Physician Payment Schedule (MPFS), chiropractors are experiencing a 5.37 MPFS percent cut this year.  

Cyber-crimes in the healthcare industry are on the rise in the United States.

Are your payments at risk?  Challenged with Eligibility? 

In mid-Summer 2021, the NYSCA issued a memorandum in response to a question about whether chiropractors as merchants could levy a surcharge on a patient who used her credit card to pay for her deductible, copayment or visit charge in order to offset the credit card companies processing fees often referred to as “swipe fees.”

On Wednesday, November 29, 2023 NGS Medicare released a statement that the calendar year (CY) 2024 Medicare Physician Fee Schedule (MPFS) is now available. You can view the new fees using the Fee Schedule Lookup tool located on NGSMedicare.com.