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NYSCA Responds to Aetna’s 2007 PPO In-Network Fee Schedule

Insurance committee recently submitted a letter to Aetna which we hoped would persuade Aetna to re-assess their new 2007 PPO In-Network fee schedule. In the letter, we raised the five issues noted below: 1. Notification of Fee Schedule Changes: Fees were reduced without proper notification to your chiropractic panel members. Should participating doctors have advance notice to their fee schedule? If Aetna’s profitability falters, are Aetna’s salaried employees given notice prior to their reduction in salary or benefits? Even if there is found to be no legal obligation, is there no moral compulsion to treat in-network providers fairly? 2. Parasitic vs. a Symbiotic Relationship with Aetna Providers: Are In-network providers considered as members of the Aetna team? According to an Aetna press release (Feb. 8, 2007; found on the web at, there was a 29% increase in net operating income in 2006 vs. 2005. Why penalize members of your team, who in part, were responsible for this success? Philosophically, the survival of any provider contract should be predicated on a symbiotic relationship. If provider fees become predatory, then the relationship becomes parasitic and is doomed to failure. The desire to obtain short term financial gains may have dire long-term consequences, and the fall off may be precipitous rather than gradual. 3. Disproportionate Cutbacks in Chiropractic Reimbursement: Why were Aetna’s In-Network chiropractic codes reduced by 28%, while therapies and modalities were only lowered by 8 to 10%? Was this meant to be a direct assault on chiropractic? Is this in line with a pay-for-performance concept? Is this backed by the current literature or just performed at the whim of an anti-chiropractic stand by Aetna? If on the other hand, it is Aetna’s long-term goal to eliminate the chiropractic panel, then I see nothing wrong with your present tactics. Is Aetna’s long-term goal to eliminate the chiropractic panel? 4. Maintaining quality of care and subscriber enrollment: Being that there is no change in reimbursements to out-of-network providers (who receive ‘Reasonable & Customary”), are there any concerns as to attracting and keeping a high quality of provider within the Aetna network? I would think that a higher quality of provider leads to a higher patient satisfaction and more enrollees. A loss of good chiropractors from the panel can result in an attrition of Aetna enrollment (a reversal from the current trend). 5. Foster Team Spirit or Animosity & Resentment: In light of the fact that Aetna’s recent trend is toward greater (rather than lesser) profitability, In-network providers feel discouraged and betrayed by a lowering of their fee schedule. Both Aetna and Aetna’s providers are faced with increasing costs of operation; but whereas Aetna appears to be doing better, the same can not be said for their providers. The reduction just adds insult to injury, and fuels resentment as we care for your Aetna subscribers. Are In-Network providers considered part of Aetna’s team, or are we to be Aetna’s adversaries? The NYSCA has recently brought similar issues to another major carrier in the New York region, and they have agreed to return the fee schedule to the 2006 schedule. We sent a broadcast fax to all the chiropractors in NYS applauding the responsiveness of this Insurance Carrier. We will anxiously await your responses (or lack there of) so we can inform NYS chiropractors as to where Aetna stands on these issues discussed. Unfortunately, we just got word that Aetna will not change the new fee schedule, and Aetna has made a conscious decision not to respond to our letter as it can only lead to dissension. Many members are concerned that NYSCA is not fighting for our survival. Can members please send constructive suggestions as to how we might deal with situations such as this?

Incorrectly Denied Claims – CO-56

National Government Services, Inc. recently discovered a claims processing system problem that affected all Medicare Part B New York claims received on, or in process on, April 23, 2007 and April 24, 2007. The affected claims were denied incorrectly with remittance advice denial message CO-56, “claim/service denied because procedure/treatment has not been deemed ‘proven to be effective’ by the payer.” National Government Services is treating this problem with the highest priority and is in the process of identifying all claims that have been affected by this error. All impacted claims will be reprocessed. We recommend that you resubmit your claims if you received the CO-56 denial, but wait for National Government Services to perform the claim adjustments. We apologize for any inconvenience this may have caused. CPT codes, descriptions, and other data only are copyright 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.

Senate OKs Health Ins Mandate Bill

The state senate has approved legislation sponsored by Sen. James L. Seward (R-C-I/Milford) that would create a state panel to review proposed health insurance mandated benefits to analyze their costs and impact on the cost of health insurance. Senate bill 3020 was approved by the senate unanimously. "Almost three million New Yorkers do not have health insurance, and for others, its rapidly escalating cost is putting affordable health coverage out of reach," Seward said. "Over the years the legislature has enacted legislation requiring that health insurance cover more than 30 different services, treatments and providers, and they all come with a cost." The legislation establishes the "health care quality and cost containment commission," the purpose of which is to analyze and report on the impact of proposed health insurance mandates. It would be charged with a) investigating the current practices of health plans; b) evaluating potential premium impact as well as avoided costs; c) analysis of current medical thinking to determine the mandate's affect on health care quality. The 2006-07 state budget includes a $300,000 appropriation for the commission, which would be included in the state insurance department. "Studies have shown that coverage of mandated services has increased premiums by 12 percent," Seward said. "And every one percent jump in insurance premiums means that 30,000 New Yorkers lose their health insurance. The commission will review mandates and advise the legislature on their estimated costs so that the legislature can make an informed decision on a particular mandate bill." The measure is sponsored in the assembly by Alexander "Pete" Grannis. "The best health insurance coverage is of no value if no one is able to afford it," Seward said.

Correction -- Urgent Attention Required -- ACN/Aetna Workers’ Compensation Access, LLC Program

ACN/Aetna Workers’ Compensation Access, LLC Program Last month, NYSCA sent out a notice concerning ACN’s mid-December mailing announcing a “new network access program” – the “Aetna Workers’ Compensation Access, LLC Program,” a Workers’ Compensation (WC) Preferred Provider Organization (PPO). Unfortunately, the NYSCA has learned, an ACN staffer gave out the wrong fax number participating providers to use if they were interested in opting-out of the ACN/Aetna program. Since the error was ACN’s, the NYSCA feels that ACN should honor opt-out requests sent and received already albeit to the wrong ACN facsimile number. Nonetheless, to be doubly sure that opt-out information has been properly received, the NYSCA recommends that providers re-fax their opt-out letters again to (763)595-3333, even if you sent an opt-out letter once already. It is the Association’s understanding the correct facsimile number for opting out of this program is (763)595-3333. Remember, this offer on the part of ACN and Aetna is not magnanimous. Everyone, but you and patients injured on the job, may benefit from this program. In theory PPO providers offer their services at a discounted rates with the hope of gaining a larger volume of covered patients attracted by the lower fees which more than offsets the discounts being offered. Although the theory works fine for payers, providers rarely see the boost in practice volume necessary to offset the loss in income from discounting their fees. Keep in mind too, that if you agree to join this Aetna/ACN WC PPO network your fees will be discounted off of the already low NYS WC fee schedule. As NYSCA noted before, one of the most frequent complaints the NYSCA receives questions why the chiropractic WC fees are so low and why they have not increased in more than ten (10) years. Furthermore, it is the NYSCA’s understanding that subsequent to the original ACN/Aetna mailing, ACN/Aetna sent out a revised fee schedule, one that more closely reflects the few services chiropractors can bill for under the NYS WC fee schedule. If you sign onto this program, in effect, you are directing Aetna/ACN to discount your already low WC fees. Caveat Scriptor. Remember too, to beware of fine print with hidden liabilities. By joining the Aetna WC PPO not only will signers discount their fees but they will be subject to other provisions of NYS Law embedded in the WC law. For example, the “Compliance” portion of the Appendix accompanying the ACN/Aetna solicitation references NYS WC Article 10A directing WC PPOs like the ACN/Aetna program to comply with other portions of NYS law, including Article Art 49 of the Public Health Law. Under Art. 49 Aetna/ACN WC PPO are “utilization review agents” required to “determine whether health care services that have been provided, are being provided or are proposed to be provided to a patient . . . are medically necessary.” By signing this agreement you will not only be agreeing to discount your fees but you will be agreeing to whatever treatment parameters Aetna/ACN decide are medically necessary for your injured WC patients. Caveat Scriptor. And as the NYSCA pointed out before, Aetna and ACN are not creating any new lines of business in New York. WC law already requires every employer to cover employee injuries received on-the-job either by self-insuring or through the purchase of WC insurance. Aetna and ACN are not adding any volume of new, untapped patients that you do not have access to already. To the contrary, Aetna and ACN are only creating new lines of business for themselves at your expense. They are offering your services at discounted fee$ to employers with the added prospect that utilization will be controlled as well. This inures to the benefit of Aetna/ACN and employers who contract with their WC PPO.its contracted employers. If you think you deserve le$ or that Aetna/ACN needs more profit at your expense, then . . . Caveat Scriptor. ACN Group has not been telling participating providers that they can opt-out of this program. In order to do so, it is the NYSCA’s understanding that participating providers must affirmatively opt-out by faxing a letter to the ACN Group at (763)595-3333 advising ACN/Aetna them that you “formally withdraw your participation in and from the Aetna Workers’ Compensation Access, LLC Program.” It is also recommended that you make clear your intent to remain in network with any other ACN Group products in which you are currently enrolled, if you choose to do so. Even if you sent an opt-out fax once already to the previous number ACN communicated in error, to be doubly sure your opt-out letter is properly received, the NYSCA recommends that you re-send your opt-out letter to the following number: (763)595-3333. For definitive opt-out information contact ACN Provider Services at 888-676-7768.

Congress Reverses Select Medicare Payment Cuts

Arlington, Va. – Congress, in one of the final acts of the session, passed legislation that halts a 5 percent cut in Medicare physician fees. The reduction would have gone into effect on Jan. 1, 2007, in addition to the 8 percent cut doctors of chiropractic will incur in February 2007. Instead, the Tax Relief and Health Care Act of 2006, the omnibus bill that contained the physician fee provision, provides no increase in the congressionally mandated sustainable growth rate (SGR) mechanism which works to hamper spending in the Medicare program. The president is expected to sign the bill. “The ACA is pleased that Congress has halted this portion of the upcoming cuts in physician Medicare payments,” said ACA President Dr. Richard G. Brassard. “It is completely unreasonable to expect providers to take on further financial constraints when they are already being hit from all sides with fee decreases. We applaud this move as a significant recognition of the increasingly stressful environment for physicians in Medicare.” Although the Tax Relief and Health Care Act of 2006 provides some measure of relief, providers in Medicare still face many types of fee cuts for 2007. Under a final rule—issued by CMS per the congressionally mandated five-year review of the work values of billing codes—doctors of chiropractic will face an average 8 percent cut starting in February 2007. This rule also imposes significant cuts to radiological and imaging services. The bill also includes a provision that will allow for a 1.5 percent increase in reimbursement for providers who report on existing quality measures established by CMS. Quality measures are developed by several different organizations through a rigorous process grounded in evidence-based medicine. The measures, approved by CMS, are geared toward primary care practices and have been utilized in the Physician Voluntary Reporting Program. “The ACA will continue to lobby on behalf of its members for fair reimbursement of Medicare services. It is imperative that Congress and the Department of Health and Human Services develop a permanent solution to the physician fee schedule because those most affected by this annual dilemma are not doctors, but patients,” Dr. Brassard said. Because the fee schedule has many different components, including a geographic consideration, doctors of chiropractic should contact their local Medicare carriers/contractors for information on what their fees will be in 2007. The 8 percent decrease is only an average and percentages may vary depending on location. Therapy Caps For most chiropractors—with the exception of those participating in the Medicare Demonstration Project—coverage of chiropractic services is specifically limited to treatment by means of manual manipulation of the spine. However, the ACA has received numerous questions concerning therapy caps. Also included in the Tax Relief and Health Care Act of 2006, the President authorized CMS to continue an exception process for Medicare beneficiaries to apply for medically necessary therapy services if their treatment is expected to exceed the cap in 2007. The ACA will provide more information as it becomes available.

UnitedHealth Group Board Announces Series of Actions

The Special Review Committee of the Board of Directors of UnitedHealth Group (NYSE: UNH) and its independent counsel, Wilmer Cutler Pickering Hale and Dorr, have completed a review and report of UnitedHealth Group’s stock option practices and reported the findings to the non-management directors. A copy of the WilmerHale report is available at: Wilmer Hale Report. Copies of the report have been sent to the Securities and Exchange Commission and the Department of Justice. In accepting the report, the Board of Directors today announced the following actions and decisions: 1. William W. McGuire, M.D. will leave the company on or before December 1, 2006, and he stepped down today as Chairman of the Board and as a Director. Between now and his departure, he will continue as Chief Executive Officer and will assist in an orderly transition to new leadership. The Board expressed its appreciation for the extraordinary contributions made by Dr. McGuire over the past 15 years. Under his leadership, UnitedHealth Group has had an enormous positive impact on the American health care system, making significant contributions in improving accessibility and making the health care system more affordable; the company became an industry leader with revenues growing from approximately $600 million to more than $70 billion. The stock price of UnitedHealth Group rose by almost 8500 percent, more than 30 times the growth of the S&P 500. The employees, shareholders and customers of UnitedHealth Group have all benefited from his leadership, energy and vision. 2. The Board elected Stephen J. Hemsley to succeed Dr. McGuire as CEO upon Dr. McGuire’s departure from the company. Mr. Hemsley joined the company in 1997 and has been the company’s President and COO since 1999. 3. The Board has created the position of non-executive chairman of the UnitedHealth Group Board. 4. The Board has elected Richard T. Burke, founding CEO of UnitedHealth Group, and a director since 1977, to the position of non-executive chairman, effective immediately. 5. The Board has accepted the resignation of board member William G. Spears, who had remained with the Board for the past six months to see the review process through to completion. The Board is grateful to Mr. Spears for his many contributions during his 15 years of service to the company. 6. David J. Lubben will proceed with plans to retire and is stepping down today as General Counsel and Secretary. He will remain with the company to effect an orderly transition of his responsibilities. The Board is grateful to Mr. Lubben for his 25 years of outstanding service and commitment to the company, both as in-house counsel and his prior contributions as outside counsel. 7. The Board has instructed Mr. Hemsley to review the conduct of senior executives in the legal, human capital and accounting functions of the Company and recommend any additional personnel actions to the Board should they be necessary. 8. Mr. Hemsley has voluntarily agreed to reprice all options awarded through 2002 to the annual high share price for each year, and to take any other appropriate action to eliminate any possible financial benefit from options-related issues identified in the report. The Board expects similar actions by Mr. Lubben and the company’s most senior executives. 9. Dr. McGuire has voluntarily agreed to reprice all options awarded to him from 1994 through 2002 to the annual high share price for each year to eliminate any possible financial benefit from options dating issues identified in the report. The company is engaged in discussions with Dr. McGuire concerning the terms of his departure from the company, including other options issues and financial benefits. The company expects to conclude the discussions on or before December 1, 2006. In addition to the steps above, the Board is taking the following actions with respect to the corporate governance of UnitedHealth Group. 10. The Board will have five board seats filled by new independent directors over the next three years in order to bring new experiences, expertise and perspectives into its membership. 11. A new senior executive position of Chief Legal Officer will be established and a national search for candidates will be conducted. 12. The position of Chief Ethics Officer will be made a senior executive position with responsibility for communicating and monitoring compliance with standards of ethical conduct and business integrity by all of the Company’s employees. 13. The position of Chief Administrative Officer will be made a senior executive position with responsibility for the Company’s critical administrative functions and non-business operations, including human capital, personnel, compensation, compliance, internal audit and business risk management, and staff support functions. 14. A separate position of Secretary to the Board, who will report to the Board with an administrative reporting line to the Chief Legal Officer, will be established. The sole responsibility of the Secretary will be to support the activities of the Board and of its Committees, including ensuring that the Board’s activities and recordkeeping are in line with corporate best practices. The actions on corporate governance announced today follow steps taken by the Board earlier this year to improve the Company’s corporate governance and compensation practices. These include: Board Structure and Process • Appointing co-lead directors (these positions have been replaced as of today by the position of non-executive chairman). • Recommending that the Shareholders amend the Company’s Charter to eliminate the classified board, so that all directors would be elected annually • Recommending that the Shareholders amend the Company’s Charter to remove supermajority approval requirements • Establishing a Public Responsibility Committee to focus on the Company’s corporate social responsibility • Initiating the review and enhancement of the Company’s director independence standards • Requiring all Audit Committee members to be financial experts as defined by the SEC • Limiting the number of boards on which directors may serve • Requiring that all directors attend ISS accredited director training Director and Officer Compensation • Reducing Board compensation by 40 percent, following a reduction of 20 percent in 2005 • Discontinuing equity awards to a number of senior executives, including the CEO and President • Initiating the process of amending the employment agreements of the CEO and President to cap SERP benefits; require reimbursement to the Company for any personal use of corporate aircraft; eliminate any tax gross-ups payable in connection with the personal use of corporate aircraft; and eliminate certain perquisites including life insurance and disability premium payments not generally available to other employees and Company-funded post-retirement health insurance • Initiating the process of amending the employment agreements of all senior executive officers to remove any enhanced severance payments upon a change of control • Establishing stock ownership guidelines for directors and executive officers Controls Over Stock Options and Other Equity Awards • Eliminating all delegated authority to management to make equity awards • Requiring that broad based equity awards to the Company’s executives and employees occur annually and be approved at the Board meeting that generally coincides with the Company’s Annual Meeting • Requiring that awards made to new hires, or for promotions or other important and valid business purposes, only be made and approved at a subsequent regularly scheduled quarterly meeting • Significantly enhancing the Company’s approval processes and internal controls related to stock option granting and administration. The WilmerHale team was led by William R. McLucas, former Director of Enforcement of the Securities and Exchange Commission. During the inquiry, WilmerHale reviewed more than 26 million pages of materials and conducted more than 80 interviews of UnitedHealth employees, present and former directors and former auditors.

American Chiropractic Association Assails Proposed Medicare Payment Cuts

DCs Could Face 13.1 Percent Reduction in Medicare Reimbursement Rates The American Chiropractic Association (ACA) is calling on Congress to halt proposed reductions in Medicare physician payments scheduled to take effect Jan. 1, 2007, that could seriously jeopardize access to care for millions of Medicare patients and would significantly reduce chiropractic reimbursement rates under Medicare. ACA says that changes recently proposed by the Centers for Medicare and Medicaid Services (CMS) as part of a congressionally mandated five-year review undermine Congress’ goals of preserving patient access and achieving greater quality of care. The association is pressing for a one-year delay in implementation of the cuts to provide CMS more time to assess the negative impact of the changes. ACA is also pressing Congress for action on another possible Medicare cut, which involves a legally mandated formula—the Sustainable Growth Rate (SGR)—to control Medicare spending. ACA is urging Congress and CMS to explore alternatives to the “inequitable” formulas used to determine physician reimbursement and to correct the system that consistently leaves millions of beneficiaries’ care in jeopardy each year. Proposed Cuts Vary Among Provider Groups This action comes on the heels of two proposed notices released by CMS that outline its plan to revise the way it calculates “relative value units” (RVUs) – or the costs associated with various health care services – under the Medicare physician fee schedule. CMS has proposed to offset an increase in payments to physicians who use higher-level evaluation and management (E/M) services by applying a budget neutrality adjuster across work RVUs for all health care services by 10 percent. This adjuster results in significantly different outcomes depending on the codes a given provider community uses. While some physicians will benefit from the increase in payments for higher-level E/M services, many health care providers will experience a dramatic overall decrease in reimbursements – particularly those providers who cannot bill for or do not frequently use higher-level E/M codes when submitting Medicare claims. In fact, certain health care professionals could experience payment cuts of as much as 15 percent by 2010 in this area of the Medicare payment formula alone. In 2007, doctors of chiropractic are slated to take an 8 percent cut in reimbursement. These cuts under the proposed notice would come in addition to a projected 5.1 percent reduction in payments based on the Sustainable Growth Rate (SGR) – a formula used to control the growth in Medicare. The combination of these requirements and proposals would result in a 13.1 percent total decrease to chiropractic reimbursement rates effective January 1, 2007. ACA Seeks Long-term Solution In addition to seeking immediate congressional action to delay the proposed rule, ACA is pressing for a fix to the Sustainable Growth Rate (SGR) formula. It is advocating not only for addressing next year’s 5.1 percent payment cut, but also to create a long-term policy solution that would lead to more accurate physician reimbursement. “Congress needs to act to halt or fix each of these cuts. CMS should explore ways to value patient time without reducing patient access to care by providers who would be forced to limit services due to such severe reimbursement cuts,” said Richard Brassard, DC, president of the American Chiropractic Association. “Preventing these cuts will ensure that Medicare beneficiaries continue to have access to valuable health care services, including doctors of chiropractic.” How Can Doctors of Chiropractic Help? The American Chiropractic Association is urging its members and chiropractic patients to lobby Congress on this issue before a final rule is unveiled by CMS later this year. Specifically, the ACA is asking doctors of chiropractic to contact their U.S. Representatives and Senators and ask them: To delay for at least one year implementation of the proposed rule as published in the June 29, 2006, Federal Register (71 Fed. Reg. 37170). Preventing these cuts will ensure that Medicare beneficiaries continue to have access to valuable health care services. In delaying implementation, Congress should also require CMS to determine the impact that these severe payment cuts will have on patient access to services. To sign on to the Cardin-Johnson Letter. A letter is being circulated around the U.S. House of Representatives that asks for Congress to take action and prevent the 5.1 percent decrease to the SGR from taking effect. Available on ACA’s Web site is a list of members of Congress who have NOT signed onto this letter as of Sept. 7. If your member of Congress is on this list, please contact him/her and ask them to sign onto this important bi-partisan letter. If your member is not on the list, please contact them and thank them for their support. Representatives and Senators can be reached via the Capitol switchboard at (202) 224-3121 or via the ACA Legislative Action Center. For more information, visit ACA’s Web site at:



On August 14, 2006, Governor Pataki announced a comprehensive plan designed to extend the time for employees and volunteers injured in the rescue, recovery and cleanup operations after the September 11, 2001, terrorist attacks on the World Trade Center to file a claim for workers' compensation benefits and to receive prompt access to medical benefits while their claims are being litigated. Although it has been almost five years since the tragic events of September 11th, many people who participated in the rescue, recovery and cleanup efforts may have hidden health issues or suffer serious, disabling medical conditions that developed more than two years after their participation which may entitle them to workers' compensation benefits. Workers' Compensation Law, Article 8-A As a key part of his plan, Governor Pataki signed into law Article 8-A of the Workers' Compensation Law (hereinafter "WCL"), which extends the time for employees and volunteers who participated in rescue, recovery and cleanup operations following the September 11, 2001 terrorist attacks on the World Trade Center to file claims for workers' compensation benefits, provided they register with the Board before August 14, 2007. (Chapter 446 of the Laws of 2006). In order to register, those employees and volunteers who participated in World Trade Center rescue, recovery and cleanup operations (hereinafter "WTC operations") must file with the Workers' Compensation Board (hereinafter "Board") a sworn statement, on Form WTC-12, listing the dates and locations of their participation in the rescue, recovery and cleanup efforts. The filing of the registration form (Form WTC-12) does NOT constitute the filing of a claim. The filing of the sworn statement does however extend the time to file a claim. With respect to claims that were previously filed and denied as untimely under WCL §18 or §28, upon the filing of the sworn statement the claim will be reopened by the Board to reconsider this claim. This new legislation is effective immediately and is deemed to have been in effect since September 11, 2001. It will apply retroactively. A number of key terms are defined in new Article 8-A. WCL §161 defines a "participant in World Trade Center rescue, recovery or cleanup operations" as any employee or volunteer, who between September 11, 2001 and September 12, 2002: (i) participated in the rescue, recovery or cleanup operations at the World Trade Center site; (ii) worked at the Fresh Kills Land Fill in New York City; (iii) worked at the New York City morgue or the temporary morgue on pier locations on the west side of Manhattan; or (iv) worked on the barges between the west side of Manhattan and the Fresh Kills Land Fill in New York City. The term "World Trade Center site" is defined as "anywhere below a line starting from the Hudson River and Canal Street; east on Canal Street to Pike Street; south on Pike Street to the East River; and extending to the lower tip of Manhattan." Finally, a "qualifying condition" means "any latent disease or condition resulting from a hazardous exposure during participation in" WTC operations. This legislation also modifies the employer notice requirements with regard to claims for "qualifying conditions" resulting from participation in WTC operations. Under the Workers' Compensation Law, a claimant is required to provide notice of a work-related injury to his or her employer "within thirty days after the accident causing such injury" WCL §18. However, pursuant to WCL §163, a claimant with a "qualifying condition" will have two years from the date of disablement or the date when he or she knew or should have known that the latent condition was causally related to his/her participation in WTC operations to provide notice to the employer who employed the participant at the time of his/her participation in the rescue, recovery or cleanup operations. In the case of a volunteer, the volunteer must provide notice to the Board within two years of the date of disablement or the date when he/she should have known that the latent condition was causally related to his/her participation in WTC operations. Article 8-A applies to all pending and future claims filed or to be filed by participants in the World Trade Center rescue, recovery and cleanup operations, including those claims already disallowed because timely notice was not given to the employer (WCL §18) or the claim was not timely filed with the Board (WCL §28). WCL §165 expressly provides that claims previously brought by employees and volunteers who participated in WTC operations, which claims were disallowed based on the claimant's failure to provide timely notice to the employer or to file a timely claim for benefits, will be reopened and redetermined in accordance with the provisions of WCL Article 8-A, provided the claimant files a sworn statement with the Board before August 14, 2007. WCL §166 makes clear that claims brought by employees who participated in WTC operations in the course of their employment will be the liability of the insurance carrier on the risk for the employer on the date that the employee last participated in WTC operations, which is considered the date of accident. With respect to claims by volunteers, WCL §167 provides that benefits will be payable out of federal funds appropriated to the Board for that purpose. However, the uninsured employers' fund shall be deemed to be the employer only for the purposes of administering and paying claims for which it will be reimbursed from federal funds. Benefits to volunteers are payable to the extent that federal funds are appropriated and available for that purpose. Employees and volunteers who participated in rescue, recovery and/or clean-up operations at the World Trade Center site, the Fresh Kills Landfill, the New York City morgue or temporary morgue or the barges between the west side of Manhattan and the Fresh Kills Landfill between September 11, 2001 and September 12, 2002, who were exposed to hazardous conditions must file the registration statement, Board Form WTC-12, before August 14, 2007, in order for the provisions of Article 8-A to apply. Employees and volunteers who do not file the registration statement before August 14, 2007, will not have the benefit of the statute of limitations and notice provisions in Article 8-A. Instead, such claims will be governed by the provisions of WCL §18 and §28, which require notice to the employer within 30 days of the accident and the filing of a claim within two years. Payment Without Prejudice WCL §21-a allows an employer or its insurance carrier to pay workers' compensation lost wage and medical benefits to an injured employee for up to one year without admitting liability for the claim and without prejudice to its right to controvert the claim. At any time during that one-year period, the employer or carrier may provide notice that it is ceasing temporary payments and may then controvert the claim if its investigation reveals that it should not be liable. Rather than automatically controverting the claim, self-insured employers and workers' compensation insurance carriers are encouraged to voluntarily pay lost wage and medical benefits pursuant to WCL §21-a in those claims in which liability is uncertain and more time is needed to investigate the claim. Doing so will provide benefits to injured claimants, while preserving the right of an employer or carrier to later controvert a claim based on the results of its investigation. The employer or carrier is required to provide notice to the claimant and the Board that payments without prejudice have begun by filing Form C-669. Termination of temporary payments by the employer or carrier must be in accordance with the five day notice provisions of WCL §21-a (3). Temporary Payment from Volunteer Fund In claims arising out of employee participation in World Trade Center operations which are controverted by the self-insured employer or insurance carrier, the Board, in the interest of justice, has directed the World Trade Center Volunteer Fund to temporarily pay for a claimant's causally related medical treatment, until liability for the claim is ultimately determined. The World Trade Center Volunteer Fund is the money appropriated by the federal government to the Uninsured Employers' Fund (hereinafter UEF) for claims of volunteers. If claimant's employer or its insurance carrier is ultimately determined to be liable for the claim, the employer or carrier will reimburse the UEF for the cost of medical treatment paid while the claim was being litigated upon demand therefore. Any notice of decision containing a finding that the employer or its carrier is liable to pay the claim will include a direction to the employer or carrier to reimburse the UEF for amounts paid from the World Trade Center Volunteer Fund within thirty days from presentation of a demand by the UEF for reimbursement. Self-insured employers and insurance carriers who have controverted claims by employees for injuries or illnesses caused by participation in WTC operations, which have not yet been established, are directed to submit to the Board within 15 days of the date of this Announcement, and monthly thereafter, an itemized list of all medical bills to be paid from the World Trade Center Volunteer Fund detailing the date of treatment, name and address of the medical provider, diagnostic codes and the amount of the outstanding medical bill(s). The medical bills and the accompanying medical reports must be attached to the itemized list. Board Form WTC-16 MUST accompany each itemized list with attached medical bills and accompanying medical reports sent to the Board for payment initially and monthly thereafter. Health Providers must still request authorization from the self-insured employer or insurance carrier. The self-insured employers and carriers are directed to timely respond to all requests for authorization for special medical services pursuant to the procedures outlined in WCL 13-a(5) and 12 NYCRR 325-1.4(b). Health Providers must continue to forward medical bills to the insurance carrier of record. Reimbursement for pharmaceutical expenses will be accepted although reimbursement for claimants travel allowances will not be payable from this fund. Employer/Carrier Approval of Medical Treatment Medical providers are required by law to seek prior approval from the employer or its insurance carrier for any procedure costing more than $500. Sometimes the required approval cannot be obtained in a timely fashion. Recognizing this, the Board developed a procedure in 2002 to enable medical providers to request Board intervention whenever an employer or insurance carrier fails to promptly respond to a request for authorization, a procedure commonly referred to as the "MD-1 process". See WCB Subject Number 046-116, issued November 24, 2003. Employers and insurance carriers are urged in all cases, and particularly in those claims arising out of an employee or volunteer's participation in WTC operations following the September 11, 2001 attacks, to promptly respond to all requests for authorization of medical treatment. Additionally, medical providers are strongly encouraged to take advantage of the Board's MD-1 process when they do not receive a prompt response to a request for medical authorization. Donna Ferrara Chair

Humana Agrees to Proposed Settlement with Chiropractors, Non-MD Providers for $3.5 Million

(Arlington, Va. - Aug. 16, 2006) Humana has agreed to a class action settlement resolving claims on behalf of chiropractors and other health care providers in Solomon v. Anthem, et. al., pending before Judge Frederico Moreno of the U.S. District Court for the Southern District of Florida. The ACA participated, through its counsel, in the settlement discussions and is a signatory to the proposed class action settlement agreement. If approved by the Court, Humana will pay $3.5 million to fund payments to class member chiropractors and other health care providers as well as fees and costs advanced by class counsel. Plaintiffs in the Solomon action recently filed a motion seeking to add the ACA as a named plaintiff in the Solomon case and requesting that ACN Group, Inc. and United Healthcare Services, Inc. be added as defendants. The case against ACN, United Healthcare Services and all remaining defendants is still pending. In addition to the cash fund described above, terms of the proposed settlement agreement with Humana include: • Changes in Humana’s business practices, intended to make its claims editing process more transparent and reduce confusion and disagreement over payments. • Online information provided by Humana to help providers understand its payment decisions. • More options for chiropractors and other health care providers to challenge Humana payment decisions in the future, if necessary. • Independent external reviews to resolve billing disputes. • The appointment of an ACA representative to a newly formed Humana health care provider advisory committee, which will provide a means of direct communication on issues and concerns. “We are extremely pleased that Humana has agreed to compensate chiropractors and other non-MD providers for claims that were previously and wrongly denied,” commented ACA President Richard Brassard, DC. “More importantly, however, we are heartened that Humana has committed to improving its business practices in the future and are hopeful that other networks and insurance companies will follow suit. Doing so can only benefit the nation’s health care consumers, who also deserve fair treatment and reimbursement.” As part of the settlement, doctors of chiropractic will be permitted to assign their portion of the recovery to the ACA, if they wish to do so. For a copy of the settlement agreement, click on the link below.


540,000 New Yorkers were at Risk for Identity Theft

As Many as 540,000 New Yorkers were at risk for identity theft after a security breach was detected. Claimants of NYS Special Funds, a workers compensation carrier, recently received letters describing the possible theft of a personal computer, which contained their private information. However, it was reported today that the computer has been located and is secure. FBI is "reasonably certain" the information was not misused Read the story by clicking on the link:


ACA's Legal Efforts Against ACN Continue, Despite Adverse Ruling in Similar Class Action

Arlington, VA -- The American Chiropractic Association (ACA) continues to aggressively challenge the practices of ACN Group Inc. on multiple fronts and remains optimistic that the chiropractic profession can find relief from the managed care organization's tactics, despite an adverse ruling in a similar federal class action suit against UnitedHealthcare, a sister company of ACN. On June 19, a federal judge in Miami dismissed a national class action lawsuit brought against UnitedHealthcare and Coventry Health by 700,000 medical doctors who claimed the insurers had conspired to arbitrarily deny or reduce claims. U.S. District Judge Federico Moreno dismissed the lawsuit, known as the Shane case, due to "insufficient evidence" that the carriers conspired to deny claims in a coordinated manner. While the ACA is disappointed in this decision -- because the ruling could set a precedent and portend an adverse judgment in the Solomon case -- legal experts point out that the two cases are different and the possibility of prevailing still exists. In the Shane decision, Judge Moreno wrote that he did not condone the insurers’ practices, but he simply could not find enough evidence of a conspiracy after reviewing thousands of documents. According to ACA's legal team, the evidence ACA has compiled against ACN, which is not a party in the Shane case, is substantial and the court that made the decision in the Shane case has yet to review it. In addition, legal action is just one track in ACA's multi-pronged strategy against ACN. In addition to filing this national class action, ACA -- in cooperation with several state chiropractic associations -- is actively engaged with a number of state attorneys general, offices of insurance and boards of licensure, and the Federation of Chiropractic Licensing Boards (FCLB) regarding the tactics undertaken by ACN. According to ACA officials, these state attorneys general and state offices of insurance are reviewing the practices of ACN and other chiropractic managed care organizations and some are launching their own investigations. "The federal court's action is clearly disappointing,” said ACA President Richard Brassard, DC. “But I want to stress to the profession -- and especially to the doctors currently suffering under ACN policies -- that the ACA will exhaust every legal, administrative and political means to redress these problems. The ACA was created to fight for our patients and for chiropractic. We now have a fight of monumental proportions on our hands. We are confident we can prevail with the remedies available to us with the support of all in the profession." To augment ACA’s legal efforts, individual doctors of chiropractic and chiropractic state associations are being asked to take action by filing complaints with state regulatory agencies. In addition, doctors are encouraged to use ACA's ERISA pre-service template letters, found at, to notify patients’ employers that the benefit they purchased for the employee is not accessible when medically necessary treatment is denied.



MEMORANDUM IN SUPPORT OF A.4527/S.3340: INSURANCE EQUALITY The NYSCA Legislative Committee has been working diligently with lobbyist Don Mazzullo in an effort to promote the Insurance Equality Bill to the New York State Senate and Assembly. Accordingly, Mr. Mazzullo has composed the attached position paper, designed to enlist backing for this important bill, which has been distributed to all New York State legislators. NYSCA encourages all of its members to review the attached memorandum, since passage of the Insurance Equality Technical Corrections Bill is of great importance to all Doctors of Chiropractic in New York State


American Chiropractic Association Files Lawsuit Against ACN in Federal Court

The American Chiropractic Association (ACA) today asked the U.S. District Court in Miami to allow ACA to join as a plaintiff in the pending nationwide class action lawsuit Solomon v. Anthem, et al., and further asked that ACN Group, Inc. and United Healthcare Services, Inc. be named as additional defendants in the case. The ACA alleges that ACN participated with other managed care companies in the case in a conspiracy to illegally and systematically underpay providers by denying reimbursement for medically necessary treatment. ACA, along with other national and state health care associations, individual doctors of chiropractic and other health care providers, challenge the utilization review and payment practices of some of the nation’s largest managed care companies, including Health Net, Humana, PacifiCare Health Systems, Aetna, United Healthcare, Wellpoint Health Networks and Prudential. The case alleges that these companies, including ACN, violated the Racketeer Influenced and Corrupt Organizations (RICO) Act by systematically and illegally denying, delaying, and diminishing payments owed to chiropractors and other health care providers. Joining the ACA in its efforts against managed care companies, particularly ACN, is the Connecticut Chiropractic Association, who is also seeking to be named as a plaintiff in the litigation. The Florida Chiropractic Association is also a plaintiff. “There is simply no greater priority for ACA than to oppose what we view as the abusive tactics of ACN and other managed care organizations who systematically deny needed chiropractic care to our patients,” said ACA President Richard G. Brassard, DC. “Doctors from across the country have provided us with reports of intimidation and coercion conducted under the guise of utilization control. This can no longer be tolerated by a profession dedicated to quality patient care. The ACA intends to expend every effort and seek every possible legal remedy to put a halt to these harmful practices.” The suit calls into question the use of financially expedient cost and actuarial criteria rather than appropriate bases of medically necessary treatment for utilization review, and alleges that these criteria are purposely imposed on providers with the knowledge that they cannot be met. Through this legal action, ACA will seek damages against ACN and the other defendants in the case on a class-wide basis. It will also seek to obtain injunctive relief to bring an end to what it views as the abusive practices and procedures of ACN. “Our case involves protection of the doctor-patient relationship as to whether care will be provided on the basis of medical necessity, or based on what we believe are contrived policies and statistics skewed to maximize profits for managed care organizations such as ACN,” said ACA Chairman Lewis Bazakos, DC. Specifically, the complaint states the defendants, including ACN: -- Systematically refused to compensate health care providers for covered services; -- Processed health care providers’ claims using either automated programs which manipulate standard coding processes or use unqualified personnel to determine whether or not the service provided was medically necessary and covered; -- Downcoded and bundled legitimate claims to less costly procedures; -- Arbitrarily refused or reduced payment for certain categories of treatment; -- Systematically failed to recognize valid assignments of benefits; and, -- Delayed payments to health care providers by requesting additional documentation, even when such documents should not be required. The ACA’s overall campaign to correct the harmful practices of some managed care networks is an outgrowth of a resolution passed by the ACA House of Delegates in March 2002 formally outlining ACA’s opposition to the improper practices of chiropractic networks. “Doctors are being forced out of their practices daily by the abusive tactics of ACN and other managed care organizations. The ACA has listened to these doctors and other doctors practicing under the threat of unwarranted terminations,” Dr. Brassard said. “Like the generations of chiropractors before us, the ACA will not back away from its responsibility to protect the profession and the patients we serve. We ask the entire profession to unite with us in this effort, as the outcome will profoundly affect the way chiropractic care is provided now and in the future.” Actions at the State Level In addition to the filing of this national class action, ACA—in cooperation with several state chiropractic associations—is actively engaged with a number of state attorneys general, offices of insurance and boards of licensure, and the Federation of Chiropractic Licensing Boards (FCLB) regarding the tactics undertaken by ACN. To help augment the legal efforts underway by ACA, individual doctors of chiropractic and chiropractic state associations are being asked to take action by filing complaints with state regulatory agencies. Furthermore, doctors are encouraged to use ACA’s ERISA pre-service template letters, found at, to notify a patient’s employer that the benefit they purchased for the employee is not accessible when medically necessary treatment is denied. To view copies of pleadings filed by ACA in the U.S. District Court in Miami, or for more information on ACA's managed care initiatives, visit ACA's Chiropractic Networks Action Center.

MultiPlan Acquired by The Carlyle Group

Nation’s Largest Independent PPO Poised for Growth New York, NY – MultiPlan, Inc. and The Carlyle Group yesterday completed the previously announced acquisition by Carlyle of MultiPlan, the largest independent PPO in America. This acquisition will facilitate the growth of MultiPlan’s market share and expansion of its medical cost management solutions, which include the national PPO network, specialty networks, negotiation services and a claim transaction and information management engine. Mark Tabak, Chief Executive Officer of MultiPlan, said, “These are exciting times for MultiPlan, and MultiPlan is an exciting company for our time. We’re a significant player in a trillion-dollar market, and with new owners committed to our success we’re even better positioned for impressive growth.” Karen Bechtel, Managing Director and Co-head of Carlyle’s Healthcare Group, said, “We’re pleased to have gotten to this important stage. MultiPlan has the proven technology and management depth necessary to bring its growth plan to fruition. We look forward to supporting the company’s strategy and making this a successful investment.” Headquartered in New York, MultiPlan is the oldest and largest independent Preferred Provider Organization (PPO) network offering nationwide access to more than 4,300 hospitals, 100,000 ancillary care facilities and 450,000 physicians and specialists. MultiPlan serves a base of 2,000 large and mid-sized insurers, third-party administrators, self-funded plans, HMOs and other entities that pay claims on behalf of health plans. The company’s top 10 clients together deliver health coverage to more than 70 million Americans. About MultiPlan For 35 years, MultiPlan has helped healthcare payers and providers partner together to combat rising healthcare costs. MultiPlan serves as a single gateway to a host of primary, complementary and out-of-network strategies for managing the financial risks associated with healthcare claims. Clients include large and mid-sized insurers, third-party administrators, self-funded plans, HMOs and other entities that pay claims on behalf of health plans. About The Carlyle Group The Carlyle Group is a global private equity firm with $39 billion under management. Carlyle invests in buyouts, venture & growth capital, real estate and leveraged finance in Asia, Europe and North America, focusing on aerospace & defense, automotive & transportation, consumer & retail, energy & power, healthcare, industrial, technology & business services and telecommunications & media. Since 1987, the firm has invested $18.1 billion of equity in 463 transactions for a total purchase price of $73.2 billion. The Carlyle Group employs more than 650 people in 14 countries. In the aggregate, Carlyle portfolio companies have more than $46 billion in revenue and employ more than 184,000 people around the world.


Through private market reforms, all Massachusetts citizens to be insured by 2009 Governor Mitt Romney signed landmark legislation today that through a private, market-based reform will make health insurance available to every resident of Massachusetts within the next three years. “An achievement like this comes around once in a generation, and it proves that government can work when people of both parties reach across the aisle for the common good,” said Romney. “Today, Massachusetts is leading the way with health insurance for everyone, without a government takeover and without raising taxes.” The legislation was approved by a bipartisan 154-2 margin in the House of Representatives and a 37-0 vote in the Senate. It was signed at a Faneuil Hall ceremony attended by hundreds of people. “This would not have been possible without the courageous work of Senate President Travaglini, Speaker DiMasi, providers, insurers, consumer groups and all the other industry stakeholders who recognized an opportunity to do something historic,” said Romney. The law requires every individual in the state to purchase health insurance by July 1, 2007. Of the approximately 500,000 uninsured, about 100,000 are eligible for Medicaid, another 200,000 making less than 300 percent of the federal poverty level, but not eligible for Medicaid will receive premium assistance on an income-based sliding scale for policies with no deductibles, and another 200,000 with incomes above 300 percent FPL will be able to purchase lower-cost policies in the private market. Premium assistance will be financed by redirecting a portion of the $1 billion currently spent by state government on the uninsured. Beginning on January 1, 2008, failure by individuals to purchase health insurance will result in the loss of their state tax refund equal to 50 percent of an affordable health insurance premium. Penalties will be assessed for each month without creditable coverage. The creation of an entity, the Commonwealth Care Health Insurance Connector, will allow individuals to now purchase affordable plans on a pre-tax basis. The Connector will administer premium assistance for low-income individuals and facilitate employer contributions for both full-time and part-time workers and those working at more than one company. Eligible to purchase through the Connector are non-working individuals, working individuals at companies that do not offer health insurance, workers not eligible for coverage at their place of business such as part-timers, contractors and new employees, small businesses with 50 or fewer employees, and those who are self-employed. The legislation also enhances the goal of greater transparency in health care cost and quality through the collection and publication of data needed by consumers to make informed decisions. The information will allow consumers to compare the quality, track record and cost of hospitals and providers. The passage of the legislation moves Massachusetts closer to the implementation of a waiver that will allow the state to continue to receive $385 million in federal funding for each of the next two years. The waiver was negotiated by Governor Romney and Senator Kennedy last year, and was dependent on the state developing a “demonstration project” to reduce the rate of uninsured. The Executive Office of Health and Human Services has already begun providing details of the Massachusetts plan for review by federal Medicaid officials. Former U.S. Health and Human Services Secretary Tommy G. Thompson commended Governor Romney for signing what Thompson termed “groundbreaking legislation to provide health coverage to all Massachusetts families.” “Massachusetts is showing us a better way, one I hope policy makers in Statehouses and Congress will follow to build a healthier and stronger America,” said Thompson, a former Republican governor of Wisconsin. The Governor vetoed the creation of a new fee on businesses. The $295 per employee fee would have been assessed to employers with 11 or more full-time workers who do not offer and contribute to their employees’ health insurance. The Governor said the fee is “not necessary to implement or finance health care reform.” The Governor also vetoed a provision to provide dental benefits to adult Medicaid recipients, which will cost $75 million annually. Romney said the benefits expansion is financially unsustainable and noted that it provides a service not offered by most Massachusetts employers. Sixty percent of employers in Massachusetts do not provide dental coverage to their workers.



U.S. Senator Mike Enzi (R-Wyoming) Chairman of the U.S. Senate Health Education and Labor (HELP) Committee is the primary sponsor of S.1955, proposed legislation intended to help small businesses and associations obtain more affordable group health insurance for their employees. While well intended, this legislation would extend ERISA’s preemption to cover the small group insurance market now regulated at the state level. As a practical matter, this legislation would render useless state-enacted legislation such as chiropractic specific mandates, any-willing provider, and insurance equality laws intended to protect health care providers and consumers. If enacted into law, S.1955, would preempt all state mandated benefit legislation not just those that are specific to the chiropractic profession. Press Release LANDMARK AGREEMENT REACHED ON HEALTH INSURANCE MARKET REFORM BILL, ENZI SAYS; MARK-UP SCHEDULED Washington, D.C. - U.S. Senator Mike Enzi (R-WY), Chairman of the Senate Health, Education, Labor and Pensions Committee (HELP Committee), today announced a landmark agreement between key stakeholders on a broad-ranging health insurance bill to provide more affordable health insurance options to America’s small businesses and working families - and confirmed that the Committee will markup up the bill next week. “Working with a diverse group of Senators and business groups representing small business, we’ve bridged the gap between small business proponents of traditional AHPs and state-based interests worried about the prospects of dramatic regulatory changes in health insurance markets,” Enzi said Thursday. The bill is cosponsored by Senator Ben Nelson (D-NE) and Senator Conrad Burns (R-MT). Enzi has scheduled a mark-up of the bill on Wednesday, March 8th at 10 a.m. in the HELP Committee. Senator Nelson said: “If we don’t do something to help small businesses cope with the costs of health care, soon we will have an entire workforce without health insurance coverage. Health care premiums are experiencing double-digit growth annually; small businesses can’t keep up with the costs. As a result, fewer employers are offering health coverage and fewer employees are covered. The continuing problem of skyrocketing heath care costs is a grave threat to our working families. I am pleased to be working with the Chairman to finding a workable solution to this problem.” Senator Burns said: “The Health Insurance Marketplace Modernization and Affordability Act represents the best opportunity to bring affordable health insurance to small businesses in Montana and across the nation. I know this is a goal for all Senators, and I look forward to working with members from both sides of the aisle in achieving this important goal.” The bill, “The Health Insurance Marketplace Modernization and Affordability Act,” (S.1955) will allow business and trade associations to band their members together and offer group health coverage on a national or statewide basis in direct response to runaway costs that are driving far too many employers and families from comprehensive health insurance. Since 2000, for example, group premiums for family coverage have grown nearly 60 percent, compared to an underlying inflation rate of 9.7 percent over the same period. Designed to enhance the market leverage of small groups as well as individual policy holders, “The Health Insurance Marketplace Modernization and Affordability Act” will: give associations a meaningful role on a level playing field with other group health plans; streamline the current hodgepodge of varying state regulation; preserve the primary role of the states in health insurance oversight and consumer protection; make lower-cost health plan options available; and achieve meaningful reform without a big price tag. “We are nearing almost five years of double-digit growth in health insurance premiums – increases that have repeatedly exceeded more than five times the rate of inflation,” Enzi said. “This inflationary spiral is lowering the quality of life for countless families and hurting our economy. But those hardest hit are America’s small businesses and families outside of employer-provided insurance. Never before has there been a more urgent need to encourage market reforms like those proposed in this bill.” It responds to pleas from small business trade groups to be allowed to pool their members and provide group health insurance, called Small Business Health Plans (SBHPs) under the Enzi bill, but will also include safeguards to protect against adverse effects that could result if new group plans were given a blanket exemption from consumer protections available under state laws and regulations. Enzi praised the support of Senator Nelson and Senator Burns, the bill’s cosponsors, saying: “I’m pleased to be joined by my colleagues, Senator Nelson and Senator Burns. They bring invaluable experience to this effort and I am grateful for their commitment to this issue.” He also praised the cooperation of Senator Olympia J. Snowe (R-ME), Chair of the Senate Committee on Small Business, and Senator Jim Talent (R-MO), who have been working for years to give more affordable health insurance options to America’s small businesses. “I want to thank them for their constant efforts,” Enzi added. “We owe them thanks for never losing sight of that important goal.”

President Bush Signs Legislation Reversing Medicare Physician Fee Cuts

Arlington, Va.- President Bush signed legislation yesterday that not only reverses the current 4.4 percent Medicare physician payment reduction, which went into effect on the first of year, but will also provide automatic reprocessing of claims retroactive to Jan. 1, 2006. The legislation was included in the Deficit Reduction Act. “The ACA is extremely pleased that Congress has halted the current cut in physician Medicare payments and that they have made the change retroactive,” said ACA President Dr. Richard G. Brassard. “The return to the 2005 rate is at least partial recognition by Congress that health care providers face significant challenges in today’s practice environment.” The Centers for Medicare & Medicaid Services (CMS) said it expects contractors to begin paying new claims using 2005 rates within two days of the legislation’s enactment. In addition, doctors of chiropractic will not need to resubmit existing claims submitted between Jan. 1 and Feb. 8, 2006. Contractors will automatically reprocess any claims that used the rates effective as of Jan. 1, 2006, and will instead use the zero percent update retroactive to Jan. 1. CMS estimates contractors should be able to reprocess all claims by July 1, 2006. Providers will receive retroactive payment for the differential in a lump sum. Physician fee schedule amounts are determined by regulation and the only way they can be changed is through legislation; this puts the issue in the hands of Congress. In late 2005, Congress evaluated the issue, but technical amendments in the Senate prevented final action on this critical issue until this week. CMS, recognizing that the physician payment adjustment could increase beneficiaries’ co-payments and deductibles for previously billed services, has suggested to the Department of Health and Human Services (HHS) that if a beneficiaries’ co-pay changed on Jan. 1, 2006, a physician waiver of the amount now owed by the beneficiary should not be considered inducement. More information will be available on the ACA Web site once a final decision has been made by HHS. “The ACA will continue to lobby on behalf of its members for fair reimbursement of Medicare services. It is imperative that Congress and HHS develop a permanent solution to the physician fee schedule because those most affected by this annual dilemma are not doctors, but patients,” said Dr. Brassard. Therapy Caps For most doctors of chiropractic – with the exception of those DCs participating in the Medicare Demonstration Project – coverage of chiropractic services is specifically limited to treatment by means of manual manipulation of the spine. However, the ACA has received numerous questions concerning therapy caps. With language included in Deficit Reduction Act, the President also authorized the Centers for Medicare and Medicaid Services (CMS) to develop a new exception process for Medicare beneficiaries to apply for medically necessary therapy services if their treatment is expected to exceed the $1,740 cap in 2006. The ACA will provide more information as it becomes available on its web site.


New comp bill introduced by New York Gov.

On Tuesday, Gov. George E. Pataki introduced the 2006-2007 budget for New York State which includes a comprehensive workers compensation reform. The bill would amend the workers' compensation law, the executive law and the insurance law, in relation to compensation claims. To read the proposed WC bill click on the link below.


MVP Health Care and Preferred Care Complete Merger

Two upstate New York based health plans, MVP Health Care of Schenectady and Preferred Care of Rochester, announced today that their proposed merger has been completed creating a major new plan serving three quarters of a million members across upstate New York, Vermont and New Hampshire. "The regulatory and legal steps needed to conclude the merger have been completed, and during the months ahead MVP and Preferred care coworkers will be working together to combine two great health plans into one plan that will be a 'leading player' in the Northeast," said David W. Oliker, president and CEO of MVP Health Care. "I want to reassure current MVP and Preferred Care customers that they will not see any changes in day to day operations as a result of this merger, customers will call the same telephone numbers they've always called, talk to the same people they've always talked to, and see the same doctors and health care providers as they did prior to the merger," said Lisa Brubaker, MVP Health Care executive vice president for Rochester operations, and government programs. "The combination gives us the resources to make needed investments in technology to meet the needs of our customers and providers," she said. The company said: • Members of the two plans will see no change in their products and services; • Members, employers and providers will continue to call the same telephone numbers and work with the same people from the same offices across the new combined service area; • Jobs across the new service area will be preserved; • The new combined organization will continue to operate as a not-for-profit. Its board of directors will be a combination of current MVP and Preferred Care directors; • MVP Health Care president and CEO David W. Oliker is the president and CEO of the combined company, which will continue to operate as both MVP Health Care and Preferred Care. During meetings with employees in both Rochester and Schenectady, Oliker outlined his goals for the combined company including: -- A provider network stretching from Rochester to New Hampshire that will be seamless for members and employers. -- Product offerings that will combine the best of both MVP and Preferred Care products and that can be sold throughout the expanded market area. -- Expansion of Preferred Care Medicare programs into several MVP counties. In addition to Oliker, other members of the senior management team for the combined company are drawn from both company's management teams. Lisa Brubaker, Preferred Care senior vice president and chief operating officer will assume the newly created position of MVP executive vice president, Rochester operations and government programs. Thomas Combs, Preferred Care senior vice president and chief financial officer will become executive vice president and chief financial officer of MVP. David Field, MVP chief financial officer and chief operating officer will be the executive vice president and chief operations officer for the combined company. Dennis Allen, M.D, MVP executive vice president and chief medical officer; will have the same role in the combined company. Scott Averill, MVP executive vice president and chief marketing officer will be the chief marketing and sales officer for the combined company. Denise Gonick, Esq., MVP executive vice president and chief legal officer will hold the same position in the combined company. "These executive vice president appointments reflect a blending of the talent of the two organizations," Oliker said. This is a leadership team that will make MVP the perfect example of a well-managed and successful, regional health benefits company," Oliker said. The combined company's service area covers upstate New York, the Hudson Valley, the entire state of Vermont and southern New Hampshire.

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Appeals Court Overturns Adverse District Court Ruling; The Fight Continues

ACA’s HHS Lawsuit Continues to Reap Benefits for Chiropractic Profession (Arlington, Va. - Dec. 14, 2005) The U.S. Court of Appeals has reversed a lower court decision allowing medical doctors and osteopaths to perform “manual manipulation of the spine to correct a subluxation” on Medicare beneficiaries, paving the way for chiropractors to pursue further hearings on the issue under a new administrative review process enacted in 2003. The Dec. 13 decision represents a major step in the American Chiropractic Association’s (ACA) landmark lawsuit against the U.S. Department of Health and Human Services (HHS) and comes at a critical time as millions of Medicare patients are choosing Medicare managed care plans as part of their new prescription drug benefit. “The ACA is extremely pleased that the District Court’s ruling allowing M.D.s and D.O.s to provide a uniquely chiropractic service was nullified,” announced ACA President Richard Brassard, DC. “We are happy that the issue is now whether or not a practitioner is ‘qualified,’ not whether or not a practitioner is simply licensed. The ACA’s position has been and remains that only chiropractors are qualified by education and training to correct subluxations. Because of the appeals court’s decision, chiropractors can continue to fight to safeguard their right to be the sole providers of this service and to ensure Medicare patients’ rights to access doctors of chiropractic.” In its Dec. 13 opinion, a three-judge appeals panel overturned an Oct. 14, 2004 District Court ruling that stated: “The court will simply reiterate its conclusion that 42 U.S.C. 1395x(r) does not prevent doctors of medicine and osteopaths from performing a ‘manual manipulation of the spine to correct a subluxation.’” The appeals panel ruled that the District Court lacked the jurisdiction to make this decision and that the final decision must be made through a newly revised appeals process. Through this process, individual chiropractors file complaints on behalf of their Medicare patients through the managed care organization. From there, complaints move to an administrative law judge. The appeals panel further questioned the District Court’s opinion on the issue of which health care providers are qualified to provide the chiropractic service – not simply which providers have a license to do so. “The regulation states that ‘[I]f more than one type of practitioner is qualified to furnish a particular service, the HMO ... may select the type of practitioner to be used.’ ... (emphasis added). The HMO’s invocation of this provision would squarely present the question of whether medical doctors and osteopaths, as well as chiropractors, are ‘qualified to furnish’ the service of manual manipulation of the spine to correct a subluxation.” According to ACA’s legal team, this language suggests that simply possessing a medical or osteopathic license will not be sufficient to provide the chiropractic service; the MD or osteopath must prove that they are qualified to do so by education and training. “The appeals court decision is especially significant as seniors are being encouraged to join Medicare managed care programs in which they will find no meaningful chiropractic services,” added Dr. Brassard. “Doctors of chiropractic nationwide must familiarize themselves with the new appeals process and report on any Medicare HMO that does not offer chiropractic services through doctors of chiropractic.” The ACA is exploring ways it can assist individual doctors of chiropractic through the administrative review process and provide them with the resources and materials they need to establish their unique qualifications to an administrative law judge, if necessary. Earlier court rulings in ACA’s lawsuit against HHS, filed in 1998, have also resulted in “monumental victories for Medicare patients,” according to Dr. Brassard – the most important being the decision prohibiting physical therapists from providing manual manipulation of the spine to correct a subluxation to Medicare patients. “Before ACA filed its lawsuit,” Dr. Brassard explained, “Medicare HMOs were given the green light to misappropriate taxpayer dollars to pay non-physician physical therapists to deliver the chiropractic physician service of 'manual manipulation of the spine to correct a subluxation’ under Medicare – or to deny the service to beneficiaries altogether. That unfair and illegal practice has ended as a direct result of our lawsuit.” Other victories that occurred as a direct result of the HHS lawsuit were: The preparation and release of a government study showing the virtual elimination of chiropractic services to Medicare beneficiaries entering the Medicare Managed Care system where there is a medical doctor gatekeeper requirement; And, a government mandate that all Medicare Managed Care plans must make available and pay for manual manipulation of the spine to correct a subluxation. “The ACA and the National Chiropractic Legal Action Fund (NCLAF) thank the thousands of supporters and contributors who have stood with us through this monumental legal battle,” said Dr. Brassard. “Because of your commitment, we will continue to work together to ensure that Medicare beneficiaries receive the safe and effective chiropractic care they need and deserve.” For a copy of the Dec. 13 decision, additional information on Medicare managed care plans, and resources on the Medicare administrative review process, visit ACA’s Web site at: