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Medicare Update: Ordering X-rays through a radioligist

An article in the Medicare MLN Matters from National Government Services on April 9, 2013 indicated that the restriction of chiropractors referring to radiologists as the ordering physician on Medicare beneficiary x-rays was changed. An inquiry was sent to the ACA regarding this policy change.

According to the ACA Medicare committee, research into the MLN Provider Bulletin on April 9, 2013 indicates that the article is incorrect. The reference cited in the article related to the ordering of diagnostic tests did state there was a change. HOWEVER, the ACA checked the Code of Federal Regulations, which are current as of October 28, 2013, and the citation related to the Chiropractic Exception (42 CFR 410.32(a)(1)) has been REMOVED. We recommend that you do not use the radiologist as the ordering physician until the ACA confirms the changes. The ACA is following up with CMS for further clarification and will keep us posted.


CMS Announces Part B Deductible for 2014

CMS announces major savings for Medicare beneficiaries

Part B premiums will see zero growth; billions of dollars saved in donut hole

The Centers for Medicare & Medicaid Services (CMS) today said that health care reform efforts are eliciting significant out-of-pocket savings for Medicare beneficiaries, pointing to zero growth in 2014 Medicare Part B premiums and deductibles, and more than $8 billion in cumulative savings in the prescription drug coverage gap known as the “donut hole.”

According to CMS, since the Affordable Care Act provision to close the prescription drug donut hole took effect, more than 7.1 million seniors and people with disabilities who reached the donut hole have saved $8.3 billion on their prescription drugs. In the first nine months of 2013 nearly 2.8 million people nationwide who reached the donut hole this year have saved $2.3 billion, an average of $834 per beneficiary. These figures are higher than at this point last year (2.3 million beneficiaries had saved $1.5 billion for an average of $657 per beneficiary).

The health care law gave those who reached the donut hole in 2010 a one-time $250 check, then began phasing in discounts and coverage for brand-name and generic prescription drugs beginning in 2011. The Affordable Care Act will provide additional savings each year until the coverage gap is closed in 2020.

CMS said the standard Medicare Part B monthly premium will be $104.90 in 2014, the same as it was in 2013. The premium has either been less than projected or remained the same, for the past three years. The Medicare Part B deductible will also remain unchanged at $147. The last five years have been among the slowest periods of average Part B premium growth in the program’s history.

“We continue to work hard to keep Medicare beneficiaries’ costs low by rewarding providers for producing better value for their patients and fighting fraud and abuse. As a result, the Medicare Part B premium will not increase for 2014, which is good news for Medicare beneficiaries and for American taxpayers,” said CMS Administrator Marilyn Tavenner.

People with Medicare don’t need to sign up for the new Health Insurance Marketplace, as they are already covered by Medicare. The Marketplace won’t affect Medicare choices, and no matter how an individual gets Medicare, whether through Original Medicare or a Medicare Advantage Plan, they still have the same benefits and security they have now.



NYSCA & Council Attend Successful Meeting with NYS WCB Staff


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Reminder: HIPAA Regulations Update


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Jurisdiction K Part B Prepayment Audit Results for CPT Code 98941


A service-specific prepayment audit was conducted by the National Government Services Medical Review Department for Jurisdiction K (JK) Part B claims in Connecticut and New York. The audit focused on claims billed with CPT code 98941, (chiropractic manipulative treatment [CMT], spinal, 3-4 regions) for the following states/locations:
  • Connecticut (implemented in January 2012),
  • Downstate region of New York (implemented in April 2012),
  • NY Queens County (implemented in August 2011), and
  • Upstate region of New York (implemented in December 2011).
Medical records will be requested to verify medical necessity of the services provided, and that services were billed according to Medicare Program guidelines. If the submitted documentation does not support CPT 98941, the services will either be correctly coded to an appropriate/lower level (98940) or denied for reasons listed below.


During this audit, documentation was reviewed to adjudicate claims for payment based on the LCD and Medicare coverage guidelines. The following results are based upon the completion of the review for JK Part B.

State/Location...................May 2013.....June 201......July 2013.....Total
New York Downstate.............92.8%.........88.2%.........89.5%..........90.2%
New York Queens County......97.4%.........96.4%.........100%...........97.9%
New York Upstate.................93.3%.........79.7%.........78.4%..........83.8%

High error rates resulted from claim denials related to documentation not supporting medical necessity requirements of the LCD for Chiropractic Services (L27350). Key issues identified are:
  • Lack of patient’s specific subjective complaint – A relevant medical history in a patient’s record must indicate a beneficiary subjective complaint(s) and the area(s) of complaint(s) should correlate to the area(s) of subluxation(s) cited and/or treated.
  • Lack of functional status- Documentation does not describe a patient’s current level of functioning and activities of daily living, nor treatment goals related to functional levels.
  • Lack of objective documentation of specific level(s) of subluxation in the exam – The precise level(s) of subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine. The level(s) of spinal subluxation must bear a direct causal relationship to the patient's symptom(s), and the symptom(s) must be directly related to the level(s) of the subluxation that has been diagnosed. Documentation needs to be clearly legible without the use of abbreviations, checks or circles that provide minimal and unclear information. If using P.A.R.T (P=pain, A=asymmetry, R=range of motion, T=temp, tone, tonicity) exam, the documentation requirement must be fully met per policy. Policy requires documentation of two of the our criteria, one of which must be asymmetry/misalignment or range of motion abnormality.
  • Lack of area(s) of CMT that corresponds to subjective complaint(s) – The specific spinal area(s) that was treated on the day of the visit must be clearly documented and the area(s) treated must correspond to patient’s subjective compliant(s). Documentation needs to be clearly legible without the use of abbreviations, checks or circles that provide minimal and unclear information.
  • Treatment plan and goals not documented/not addressed – Documentation of a treatment plan must include the recommended level of care (duration and frequency of visits); specific treatment goals and objective measures to evaluate the treatment effectiveness. The patient’s progress or lack thereof related to the established treatment plan and goals should be addressed on subsequent visits. If treatment continues on without evidence of improvement or the clinical status has remained stable for a given condition, further manipulative treatment is considered maintenance therapy and is a non-covered benefit.
  • Documentation supporting maintenance – Maintenance therapy is a noncovered benefit. Examples of maintenance therapy would include long-term treatment per history without the documentation supporting exacerbation, subjective complaint of “minimal pain” on multiple visits without showing improvements or no positive response – documentation remains the same or template for multiple visits. Also, documentation of “chronic” condition with no documentation to support an exacerbation and/or improvement.
Other issues that resulted in claim denials include:
  • Nonresponse to development letters – When an ADR letter is received, submitting information and appropriate documentation suggested in the ADR letter is required to consider payment of the claim in question. If the requested medical record is not submitted in a timely manner, the services will be systematically denied.
  • Illegible Documentation – Medical record must be legible. If the reviewer cannot decipher the documentation, it may result in the denial of a claim.
  • Missing or illegible provider signature – Documentation must be legible and include a provider’s signature. The method used can either be electronic or handwritten, stamp signatures are not acceptable. A signature key or signature log can be included with the documentation to identify the author associated to the illegible signature.
  • Incomplete or missing beneficiary information – A patient’s medical record must include a legible beneficiary name for identification. Also, the medical record should be clearly dated and correspond to the date of service billed. If this information is missing or incomplete, it may result in denial of a claim.

We recommend that you perform random sample claim audits within your practice to ensure that these errors do not exist. You may also use the errors identified in the prepay audit as a checklist before submitting future claims. Please also take time to review the LCD and SIA for Chiropractic Services (L27350). The LCD and SIA can be accessed from the Medical Policy Center on the National Government Services Web site. Enter L27350 in the CMS Identifier Number search field and select Go to initiate an LCD search in the CMS Medicare Coverage Database.

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Clarification on the Treatment Categories and Requirements for Obtaining PT, OT, and Chiropractic Care


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ICD-10 Possibilities for Chiropractic Physicians


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New Claim Adjustment Reason Code (CARC) to Identify a Reduction in Federal Spending Due to Sequestration

Provider Types Affected

This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare contractors (Fiscal Intermediaries (FIs), carriers, Regional Home Health Intermediaries (RHHIs), Durable Medical Equipment Medicare Administrative Contractors (DME/MACs) and A/B Medicare Administrative Contractors (A/B MACs)) for services to Medicare beneficiaries.

Provider Action Needed

This article is based on Change Request (CR) 8378 which informs Medicare contractors about a new Claim Adjustment Reason Code (CARC) reported when payments are reduced due to Sequestration. Make sure that your billing staffs are aware of these changes.


As required by law, President Obama issued a sequestration order on March 1, 2013. As a result, Medicare Fee-For-Service claims, with dates of service or dates of discharge on or after April 1, 2013, incur a two percent reduction in Medicare payment. The Centers for Medicare & Medicaid services (CMS) previously assigned CARC 223 (Adjustment code for mandated Federal, State or Local law/regulation that is not already covered by another code and is mandated before a new code can be created) to explain the adjustment in payment. Effective June 3, 2013, a new CARC was created and will replace CARC 223 on all applicable claims. The new CARC is as follows:
  • 253 - Sequestration - Reduction in Federal Spending
Also, Medicare contractors will not take any action on claims processed prior to implementation of CR8378.

Additional Information

The official instruction, CR 8378 issued to your Medicare contractor regarding this change may be viewed on the CMS website.

If you have any questions, please contact your Medicare contractor at their toll-free number, which may be found on the CMS website.



ACA Insurance Relations: Important Decision Regarding Mechanical Traction


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Federal Agency Considers Further Chiropractic Coverage in Medicare


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Mandatory Use of Updated MTG Forms MG-1 and MG-2


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From the President: About that No-Fault regulation that takes effect on April 1, 2013...

On February 20, 2013, on behalf of the NYSCA membership, NYSCA President Dr. Bruce Silber wrote to the New York State Department of Financial Services seeking clarification of the, then, recently adopted No-Fault Regulation – FOURTH AMENDMENT TO 11 NYCRR 65-3 (INSURANCE REGULATION No. 68-C) Claims for Personal Injury Protection Benefits, I.D. No. DFS-20-12-00009-A, New York State Register, February 20, 2013, pp. 8-10.

In his query the Dr. Silber wrote:
As you may or may not recall, the New York State Chiropractic Association (NYSCA) offered comments on this regulation when it was first proposed last May. The Association has not received and has not seen any response to the observations the Association offered. The Association noted, however, that the State Register announced today (February 20, 2013) that the regulation has been adopted effective April 1, 2013.

In the meantime, a question has arisen regarding the regulation and how it will be implemented for which the Association seeks clarification. Specifically, the NYSCA seeks clarification of the following provisions:

New subdivision (g) of section 65-3.8 provides as follows:
(g) (1) Proof of the fact and amount of loss sustained pursuant to Insurance Law section 5106(a) shall not be deemed supplied by an applicant to an insurer and no payment shall be due for such claimed medical services under any circumstances:
(i) when the claimed medical services were not provided to an injured party; or
(ii) for those claimed medical service fees that exceed the charges permissible pursuant to Insurance Law sections 5108(a) and (b) and the regulations promulgated thereunder for services rendered by medical providers.

The problem area is (g)(1)(ii). Some NYSCA members have identified an ambiguity in the way these stipulations may be read.

On the one hand, it may be read that the regulation says that "no payment shall be due" for "those claimed medical service fees that exceed the charges permissible pursuant to the Insurance Law §§ 5108(a) and (b)" - that is, the WC fee schedule.

Specifically, §§ 5108(a) and (b) of Insurance Law stipulate as follows:

§ 5108. Limit on charges by providers of health services.
(a) The charges for services specified in paragraph one of subsection (a) of section five thousand one hundred two of this article and any further health service charges which are incurred as a result of the injury and which are in excess of basic economic loss, shall not exceed the charges permissible under the schedules prepared and established by the chairman of the workers' compensation board for industrial accidents, except where the insurer or arbitrator determines that unusual procedures or unique circumstances justify the excess charge.
(b) The superintendent, after consulting with the chairman of the workers' compensation board and the commissioner of health, shall promulgate rules and regulations implementing and coordinating the provisions of this article and the workers' compensation law with respect to charges for the professional health services specified in paragraph one of subsection (a) of section five thousand one hundred two of this article, including the establishment of schedules for all such services for which schedules have not been prepared and established by the chairman of the workers' compensation board.

Fees that are in "excess" - more than, above or beyond the amounts allotted in the Workers' Compensation fee schedule for individual services are not the real issue at hand here, although this is one way to read the ambiguity.

The concern that arises is that the Workers’ Compensation fee schedule permits doctors of chiropractic (and physical therapists) to be paid for only eight (8) units of treatment. Providers bill a combination of medically necessary therapies that oftentimes exceed the eight (8) units permitted. In addition, most electronic health care software programs follow the AMA CPT® coding rules and the software cannot be adjusted to bill only for, or exactly for eight (8) units or less when the services provided often tabulate for more. This is problematic since many practitioners provide and bill services in excess of the eight (8) units allotted pursuant to the revised and expanded Workers’ Compensation fee schedule. The Workers’ Compensation Board has accommodated the providers by allowing providers to bill for more than the eight (8) units payable but also stipulated that Workers’ Compensation payers would only be responsible for paying for maximum eight (8) units permitted.

If chiropractors (or physical therapists) provide and bill for services in excess of the eight (8) units allowed under the Workers' Compensation fee schedule, the No-Fault regulation adopted appears to allow insurers to deny payment automatically and in total, even though the dollar amount for services individually charged do not exceed the service dollar charges in the Workers Compensation fee schedule for those specific services.

The NYSCA does not contest the fact that providers should not be billing the payers of injured patients dollar amounts for individual and specific services that exceed the dollar amounts for individual services permitted by the Workers’ Compensation fee schedule. At the same time, however, the Association does not think it fair that the a provider’s payment could be automatically and completely denied should the practitioner provide and bill for services whose combined unit values go beyond the eight (8) units permitted by the Workers’ Compensation fee schedule, even though the dollar amounts (fees) for the individual services charges do not exceed and are consistent with the individual dollar amounts (fees) for those services found in the Workers’ Compensation fee schedule. This would be a disservice to the providers involved. If the eight (8) units of service carry over to the §§ 5108(a) and (b) fee schedule(s), then the Association feels that providers should be able to bill for services irrespective of the eight (8) unit service cap with the understanding that payers would only be obligated to pay for up to the eight (8) unit service limit.

Please clarify this ambiguity and how the Department intends on implementing this regulation.

As the deadline for implementation of the April 1, 2013 regulation looms, and not having heard from the Department of Financial Services relative to the Association’s February 20, 2013 inquiry above, I telephoned the Department of Financial Services and spoke directly to someone in the Insurance Bureau that works on No-Fault issues. After explaining the foregoing ambiguity again, the DFS representative explained that he believed the issue had been addressed in the State Administrative Procedure Act (SAPA) run-up to the regulation and that the Regulatory Impact Statement clearly states that ONLY the portion of a provider’s fee that exceeds the fee schedule will be denied, not the entire fee.

Not content to take the Department’s word, I looked up the Regulatory Impact Statement (RIS) directly and it seems to concur with the DFS statement. Under the rubric: “Preventing Billing in Excess of Mandated Fee Schedule or for Services Not Rendered,” the RIS states as follows:

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Mandatory Payment Reductions in the Medicare Fee-for-Service Program – “Sequestration”

To All Health Care Professionals, Providers, and Suppliers

The Budget Control Act of 2011 requires, among other things, mandatory across-the-board reductions in Federal spending, also known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for two (2) months. As required by law, President Obama issued a sequestration order on March 1, 2013. The Administration continues to urge Congress to take prompt action to address the current budget uncertainty and the economic hardships imposed by sequestration.

This Listserv message is directed at the Medicare Fee-for-Service (FFS) program (i.e., Part A and Part B). In general, Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment. Claims for durable medical equipment (DME), prosthetics, orthotics, and supplies, including claims under the DME Competitive Bidding Program, will be reduced by two (2) percent based upon whether the date-of-service, or the start date for rental equipment or multi-day supplies, is on or after April 1, 2013.

The claims payment adjustment shall be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments.

Though beneficiary payments for deductibles and coinsurance are not subject to the two (2) percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the two (2) percent reduction. The Centers for Medicare & Medicaid Services encourages Medicare physicians, practitioners, and suppliers who bill claims on an unassigned basis to discuss with beneficiaries the impact of sequestration on Medicare’s reimbursement.

Questions about reimbursement should be directed to your Medicare claims administration contractor. As indicated above, we are hopeful that Congress will take action to eliminate the mandatory payment reductions.

Posted 03/08/2013.



NGS Webinar - Medicare Documentation and Coverage

Medicare chiropractic service Documentation and Coverage
Join us for a Webinar on February 13

Space is limited.

Reserve your Webinar seat now at:
Medicare chiropractic service Documentation and Coverage

Title: Medicare chiropractic service Documentation and Coverage
Date: Wednesday, February 13, 2013
Time: 12:00 PM - 1:30 PM EST

After registering you will receive a confirmation email containing information about joining the Webinar.

System Requirements
PC-based attendees
Required: Windows® 7, Vista, XP or 2003 Server
Mac®-based attendees
Required: Mac OS® X 10.5 or newer
Mobile attendees
Required: iPhone®, iPad®, Android™ phone or Android tablet


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


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.


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


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.


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:


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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