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HEALTH PLANS AGREE TO PROVIDE REQUIRED COVERAGE INFORMATION

Attorney General Eliot Spitzer said today that 21 health plans operating in New York have agreed to take new steps to ensure that consumers have the information they need to intelligently shop for health coverage and obtain medically necessary care. Under the agreements, the health plans have pledged to be more responsive to requests from consumers for so-called "clinical review criteria," which is used to determine whether health care claims will be covered. In the past, health plans have sometimes failed to disclose these criteria and other essential coverage information, discouraging access to needed care. "Consumers need clear and complete information from health care plans," Spitzer said. "These agreements obligate the health plans to provide that information and help consumers make the right decisions in choosing a health plan and obtaining medically-necessary care. The agreements may also make it easier for chronically-ill New Yorkers to enroll in plans that meet their special coverage needs." The agreements stem from a March 2004 report by Spitzer's Health Care Bureau. The report found that all of the plans offering individual coverage in New York failed to comply with state coverage information disclosure requirements. In compiling the report, members of Spitzer's staff posed as prospective health plan enrollees. For example, one letter stated that the writer was a diabetic who wanted to buy an individual insurance policy. The writer requested information about how the health plan would decide whether an insulin pump would be a covered expense. Information was also sought for coverage of nutritional supplements and more serious procedures, including arthroscopic knee surgery, breast reduction surgery and surgery for Crohn's disease. Five letters were sent to each plan requesting information on the standards used to determine whether or not a treatment for five different conditions was medically necessary and therefore covered by insurance. Disclosure of this information is specifically required under the state's Managed Care Consumer Bill of Rights. Spitzer's staff analyzed the responses from the health plans and assigned the plans grades based on the number of satisfactory responses. Out of 22 plans studied, half (11) received an "F" for compliance, seven plans received a "D," three plans received a "C," and only one plan got a "B." No plan received an "A." Twenty-six percent of the 110 letters received no response from the plans at all. The clinical review criteria are extremely important to consumers with existing medical conditions because they contain the standards that the health plans use to determine whether a specific treatment is medically necessary; if not, coverage is denied and the consumer is left with the choice of either foregoing medical care or paying out-of-pocket. The State Managed Care Consumer Bill of Rights requires health plans to disclose these criteria to both current and prospective enrollees upon written request. Noting that all of the plans cooperated fully with the inquiry, Spitzer commended certain plans for agreeing to present the required information in a way that was particularly useful to consumers. For example, Excellus Health Plans, based in Rochester, agreed to make its clinical review criteria available to all consumers on its Internet website. MDNY, a Long Island health plan, agreed to translate the medical jargon in some of its criteria into simpler, lay language. Spitzer renewed his call on the Governor and State Legislature to pass legislation originally proposed by the Attorney General in 2001, to establish clear penalties for violations of the Managed Care Consumer Bill of Rights. Currently, there are no specific penalties for violations of this consumer protection statute. The settlements announced today specifically require the health plans to ensure that all consumer requests for clinical review criteria are honored and to submit annual compliance reports to the Attorney General's Office. Each plan will also pay $5,000 in costs to the state. The case was handled by Assistant Attorneys General Paul Beyer, Heather Hussar and Susan Kirchheimer, and Section Chief Troy Oechsner under the supervision of Joseph Baker, Health Care Bureau Chief. The full text of the report is available on the Attorney General's website: www.oag.state.ny.us. Consumers and providers with questions or concerns about health care matters can call the Attorney General's Health Care Bureau Hotline at 1-800-771-7755. NEW YORK HEALTH PLANS PARTICIPATING IN SETTLEMENT Aetna US Healthcare Atlantis Health Plan Capital District Physicians' Health Plan (CDPHP) CIGNA Healthcare of New York ConnectiCare of New York Empire HealthChoice Excellus Health Plan Group Health Inc. (GHI) HealthFirst New York Health Insurance Plan of Greater New York (HIP) Health Net of New York HealthNow New York Horizon Healthcare of New York Independent Health Association MDNY Healthcare MVP Health Plan Oxford Health Plans of New York Preferred Care United Healthcare of New York Vytra Health Plans WellCare of New York

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CMS SEEKS PUBLIC COMMENT ON CHIROPRACTIC DEMONSTRATION PROJECT PROTOCOLS

Centers for Medicare & Medicaid Services (CMS) announces the implementation of a demonstration mandated under Section 651 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108–173), which will expand coverage of chiropractic services under Medicare beyond the current coverage for manipulation to correct a neuromusculoskeletal condition. To view the entire announcement from the Federal Register regarding the protocols (which is three pages long) please go to: The Federal Register on Friday, January 28, 2005

CHANGE IN RATE OF REIMBURSEMENT TO CLAIMANTS FOR TRAVEL BY AUTOMOBILE

Supersedes Subject No. 150-18.1 dated December 18, 2003 In accordance with the Board resolution adopted on February 20, 1990, the mileage rate for reimbursement to claimants for travel by automobile is to be the same rate at which management/confidential state employees are reimbursed for travel by automobile. The mileage rate for reimbursement to claimants for travel by automobile on or after January 1, 2005 shall be 40.5 cents per mile. In those instances where claimants are entitled to reimbursement for travel expenses, carriers and self-insurers will allow claimants reimbursement for travel in accordance with this rate. For your information, a table of the travel reimbursement rates from 1970 to the present is below. David P. Wehner Chairman

Submitting Workers’ Compensation Claims Online

▪ Other forms available online for completion Overview/Features Workers’ Compensation (WC) allows parties of interest, including health care providers to complete claims forms, like a C-4*, and submit it online to the Workers' Compensation Board. Other Adobe Acrobat PDF versions of WC forms may be filled out online first, saved to the doctor’s computer locally, then printed and mailed to WC, or the online form may be saved to the doctor’s computer locally first, then printed out, completed and mailed to WC. For a list of forms available online, please refer to the "List of Available Forms" below. Click on the link and go to the members only section. Not a member? Click on the application on the left and join today!

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CMS CARRIERS TO DELIVER 2005 MEDICARE PHYSICIAN FEE SCHEDULE BY CD-ROM THIS MONTH

New York’s Medicare Carriers have reported that they will be sending the 2005 Medicare Physician Fee Schedule (MPFS) on a CD-ROM this month to all those providers who usually receive the Fee Schedule in booklet format. Watch for additional information on your carrier’s website. This change comes as a result of a successful pilot project conducted a year earlier.

CMS IDENTIFIES FOUR SITES FOR A MEDICARE CHIROPRACTIC DEMONSTRATION PROJECT

The Centers for Medicare and Medicaid Services (CMS) released yesterday, four sites CMS will use for a chiropractic demonstration projected required under section 651 of the Medicare Prescription Drug, Improvement, and Modernization Act. Making the announcement, CMS Administrator, Mark B. McClellan, M.D., Ph.D., announced that Medicare will conduct a demonstration project in Maine, New Mexico, Illinois and Virginia expanding coverage of chiropractic services for neuromusculoskeletal conditions. “We recognize that many Medicare beneficiaries seek the services of chiropractors for back pain and other conditions,” McClellan said. “This demonstration provides the opportunity to evaluate whether expanding coverage of chiropractic services reduces overall Medicare expenditures for neuromusculoskeletal conditions.” Beginning in April 2005, chiropractors that are located in the demonstration areas will be able to provide services to any beneficiary enrolled under Medicare Part B. The demonstration will expand coverage for the services that chiropractors provide for the care of neuromusculoskeletal conditions, including diagnostic and other services such as the provision of x-rays and therapy services. Current Medicare coverage for chiropractic care is limited to manual manipulation of the spine to correct a subluxation, which is defined as a malfunction of the spine. Treatment may only be provided for the active correction of a documented subluxation, and not for prevention or health maintenance. Treatment for the subluxation must be related in terms of a neuromusculoskeletal condition where there is a reasonable expectation of recovery or functional improvement. The goal of the demonstration is to evaluate the feasibility and desirability of covering additional chiropractic services under Medicare beyond the current coverage. CMS has scheduled an Open Door Forum on November 18 to solicit input from interested groups regarding benefits of this demonstration and implementation of its budget neutrality requirements. The demonstration will be conducted in the entire states of Maine and New Mexico, and in the Chicago Metropolitan Statistical Area (MSA) and 17 central counties in Virginia. The statue specified that the demonstration must include four sites, two urban and two rural, and one site of each must be in a health professional shortage area (HPSA). The statute requires an evaluation of the demonstration to assess cost effectiveness, cost benefit, beneficiary satisfaction, and other issues as the Secretary of Health and Human Services determines to be appropriate. ▪ ACA Concerns After fighting hard to have the demonstration project language included in the language of the Medicare Prescription Drug, Improvement, and Modernization Act, the ACA notes with some chagrin that is has some concerns with how the proposed demonstration project may be carried out. ACA staff met with CMS officials last Friday, November 6, to receive information on the status of planning for the demonstration. Subsequently, the ACA has identified several areas of concern with regard to the design, including possible infringements on full scope of practice under existing Medicare program benefits. ACA is preparing a formal and detailed response to CMS that will be available prior to CMS's November 18th, Open Door Forum on the chiropractic demonstration project. More on the project will be forthcoming in the not too distant future.

CMS IDENTIFIES FOUR SITES FOR A MEDICARE CHIROPRACTIC DEMONSTRATION PROJECT

The Centers for Medicare and Medicaid Services (CMS) released yesterday, four sites CMS will use for a chiropractic demonstration projected required under section 651 of the Medicare Prescription Drug, Improvement, and Modernization Act. Making the announcement, CMS Administrator, Mark B. McClellan, M.D., Ph.D., announced that Medicare will conduct a demonstration project in Maine, New Mexico, Illinois and Virginia expanding coverage of chiropractic services for neuromusculoskeletal conditions. “We recognize that many Medicare beneficiaries seek the services of chiropractors for back pain and other conditions,” McClellan said. “This demonstration provides the opportunity to evaluate whether expanding coverage of chiropractic services reduces overall Medicare expenditures for neuromusculoskeletal conditions.” Beginning in April 2005, chiropractors that are located in the demonstration areas will be able to provide services to any beneficiary enrolled under Medicare Part B.

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CITING ‘MONUMENTAL VICTORIES FOR MEDICARE PATIENTS,’ ACA VOWS TO CONTINUE LEGAL BATTLE AGAINST HHS

Arlington, Va. (Oct. 19, 2004) — The American Chiropractic Association (ACA) has vowed to appeal a recent decision by a U.S. District Court judge to dismiss its lawsuit against the Department of Health and Human Services (HHS), a lawsuit that protects the very heart of the chiropractic profession’s services under Medicare – manual manipulation of the spine to correct a subluxation. ACA officials said they would continue the battle until doctors of chiropractic are the only providers who can offer the profession’s core service. “While we are understandably disappointed in the judge’s decision, we take pride in the fact that our lawsuit has already put an end to years of discrimination against doctors of chiropractic and their patients,” said ACA President Dr. Donald J. Krippendorf. “Before we filed our lawsuit, 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. We strongly believe that we owe it to our patients – and have a strong legal basis – to continue our battle in an effort to prohibit medical doctors and osteopaths from correcting subluxations, a service that is uniquely chiropractic.” Dr. Krippendorf also noted the “monumental victories for Medicare patients” already achieved through the lawsuit, including: • Compelling the government to prepare and release a study showing the virtual elimination of chiropractic services to Medicare beneficiaries entering the Medicare Managed Care system; • Prohibiting federal payments to physical therapists providing manual manipulation of the spine to correct a subluxation to Medicare patients; • And, mandating that all Medicare Managed Care plans must make available and pay for manual manipulation of the spine to correct a subluxation. In his Oct. 14 decision, U.S. District Judge John Garrett Penn granted HHS a motion for summary judgment, stating that Congress did not intend for only chiropractors to provide “manual manipulation of the spine to correct a subluxation” when it established the Medicare program in 1972, and that the Medicare statute is “neither silent nor ambiguous” in this regard. According to ACA officials, the judge’s rationale is “perplexing,” given the fact that even the U.S. government itself admitted ambiguity in the 32-year-old language governing the Medicare program – and, according to the government’s own position with the court, that “Congress has not directly spoken to the precise issue of who may provide manual manipulation of the spine to correct a subluxation to Medicare beneficiaries.” “We have a responsibility to our Medicare patients to continue this fight. They deserve to have chiropractic services delivered by doctors of chiropractic,” added Dr. Krippendorf. “We believe the use of the term ‘subluxation’ at the time it was inserted in the Medicare statute was meant to assign the correction of the subluxation exclusively to doctors of chiropractic.” The ACA first filed its lawsuit in November 1998, claiming that HHS guidelines unlawfully allowed Medicare Managed Care plans to substitute the services of other health care providers for services that should legally be performed by doctors of chiropractic and that chiropractic services were not being provided under Medicare Managed Care programs. Specifically challenged in ACA's lawsuit was a 1994 “Operational Policy Letter” stating: “Managed care plans contracting with Medicare are not required, however, to offer services of chiropractors, but may use other physicians to perform this service. In addition, managed care plans may offer manual manipulation of the spine as performed by non-physician practitioners, such as physical therapists, if allowed under applicable state law.” In January 2002, as a direct result of the ACA lawsuit, HHS issued a new policy directive that, under Medicare, physical therapists could not be reimbursed for providing manual manipulation of the spine to correct a subluxation, and also added that manual manipulation to correct a subluxation must be provided by Medicare managed care plans. In a revision to the 1994 Operational Policy Letter, Medicare's Center for Beneficiary Choices wrote: “The (Medicare) statute specifically references manual manipulation of the spine to correct a subluxation as a physician service. Thus, Medicare+Choice organizations must use physicians, which include chiropractors, to perform this service. They may not use non-physician physical therapists for manual manipulation of the spine to correct a subluxation.” (emphasis added) In addition, the new policy provides: “As a standard of Medicare Part B benefit, manual manipulation of the spine to correct a subluxation must be made available to enrollees in Medicare+Choice plans.” (Updated OPL#23, Jan. 15, 2002 emphasis added.) The ACA has 30 days to file a notice of appeal to the U.S. Court of Appeals for the District of Columbia – a court that has been coined “the second highest court in the land” because many of its judges are ultimately appointed to the U.S. Supreme Court. From there, the court will issue a briefing schedule. Typically, the U.S. Court of Appeals for the District of Columbia makes a decision on cases within 12 months. “We thank the thousands of supporters and contributors within the chiropractic profession who continue to stand with us through this monumental legal battle,” Dr. Krippendorf said. “Because of your commitment to the cause, we will continue to ensure that Medicare beneficiaries receive the safe and effective chiropractic care they need and deserve, and that they receive it only from health care providers appropriately trained and skilled to provide manual manipulation of the spine to correct a subluxation – doctors of chiropractic.” FOR MORE INFORMATION: Angela Kargus or Felicity Feather Clancy 800.986.4636 | [email protected] Copy of the opinion can be found at:

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Reminder: New Requirements for Chiropractic Billing of Active/Corrective Treatment and Maintenance Therapy.

According to CMS, “Chiropractors have been submitting a very high rate of incorrect claims to Medicare. Medicare only pays for chiropractic services for active/corrective treatment (those using HCPCS codes 98940, 98941, or 98942). Claims for medically necessary services rendered on or after October 1, 2004, must contain the Acute Treatment (AT) modifier to reflect such services provided or the claim will be denied. Read more in the Members' Only Section. Not a member? Click on the application on the left of your screen and stay informed.

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NYSCA Comments Helps Prod Insurance Department Into Dropping Offending No-Fault Provisions

In response to comments the State Insurance Department (SID) received from the New York State Chiropractic Association (NYSCA) and other professional groups, individuals and organizations, on August 18, the Department published a “revised” regulatory proposal floated earlier this year that, among other things, would have pegged the fees for durable medical equipment (DME) at Medicaid levels, and, in one of the other more controversial amendments referred to as the "Concurrent Care Rule," would have required the “sharing of fees among licensed health providers or the payment of a fee only to the provider whose specialty was most relevant to the diagnosis, if more than one licensed health provider treated the patient at the same time, and the treatment involved overlapping or common services.” Read more in "Members' Only" section. Not a member? Consider joining NYSCA today to access this and other regularly updated information.

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CRIME RING IN QUEENS INDICTED FOR NO-FAULT AUTO INSURANCE FRAUD

10 People, 5 Corporations Indicted For Operating Fraud Ring in Hollis, Queens Superintendent of Insurance Gregory V. Serio and Attorney General Eliot Spitzer today announced the indictment of 10 individuals and five corporations accused of operating an insurance fraud ring out of SZ Medical, a clinic in Hollis, Queens. The defendants include nine health care providers and are alleged to have fraudulently billed an insurance carrier for months of treatment and extensive testing, including medical evaluations, diagnostics tests, physical therapy, chiropractic treatment and acupuncture. Gregory V. Serio, Superintendent of Insurance, said, "It’s particularly disturbing that this fraud ring was comprised of doctors and health care providers, professionals who are here to protect us and not betray the public’s trust by defrauding our insurance system. Thanks to our strong partnership with Attorney General Spitzer, these people have been exposed and this case will help us build more momentum in the fight against fraud." "This case demonstrates the sustained and coordinated effort required to combat the pervasive nature of auto insurance fraud," Attorney General Spitzer said. "My office will continue to work with the State Insurance Department, law enforcement, and industry officials to bring these cases. While we are making progress, there is still an extraordinary amount of work yet to do." Under the State's no-fault auto insurance law, insurance carriers reimburse medical facilities for services provided to persons injured in motor vehicle accidents. It is alleged that the defendants submitted fraudulent claims to a no-fault insurance carrier for services never provided or for services that were not medically necessary. The charges stem from a long-term investigation of SZ Medical which began in Spring, 2003. According to the indictment, the defendants fraudulently billed an insurance carrier for months of treatment and extensive testing, including medical evaluations, diagnostics tests, physical therapy, chiropractic treatment and acupuncture. The indictment charges that fraudulent claims were submitted by three medical doctors, Sergey Zavilyansky, 48, of Brooklyn; Gary Friedman, 51, of Manhattan; and Lee Craig Nagourney, 52, of Brooklyn. Zavilyansky is the owner of SZ Medical. All three are charged with fabricating medical diagnoses and submitting claims for services not provided or not medically warranted. The indictment additionally charges the following defendants with fraudulent claim submissions: Stanley Frankel, 69, of Manhattan, a dentist; Michael Ferrato, 56, of Suffolk County, a psychologist; Juby Uralil, 26, of Queens County, a physical therapist; Joel Santos, 34, of Queens County, a physical therapist; Peter Pramberger, 51, of Suffolk County, a chiropractor; and Ji Yong Kim, 39, an acupuncturist. The indictment also charges that defendant Nelson Bloom, 57, of Brooklyn, a paralegal, held himself out as a licensed attorney and directed a no-fault patient to undergo medical tests and attend the clinic for several months, without regard to medical need, in an effort to increase the potential settlement of a bodily injury claim. Five corporations are also charged in the indictment: SZ Medical, P.C.; Almaz Medical Services, P.C., owned by physician-defendant Lee Craig Nagourney; Ferrato Psychological Services, P.C., owned by psychologist-defendant Michael Ferrato; Life Chiropractic P.C., owned by defendant Peter Pramberger; and Somun Acupuncture, P.C., owned by acupuncturist-defendant Ji Yong Kim. The defendants are facing charges of Insurance Fraud in the Third Degree, a D felony; Insurance Fraud in the Fourth Degree, an E felony; Falsifying Business Records in the First Degree, an E felony; Insurance Fraud in the Fifth Degree, an A misdemeanor, Attempted Grand Larceny in the Fourth Degree, an A misdemeanor; Practicing or Appearing as an Attorney-At-Law Without Being Admitted and Registered, an A misdemeanor; Conspiracy to Commit Grand Larceny in the Fourth Degree, an A misdemeanor; and Attempted Petit Larceny, a B misdemeanor. New York is aggressive in its fight against insurance fraud. To report suspected incidents of insurance fraud call 1-888-FRAUD-NY (1-888-372-8369). It should be noted that an arrest is merely an accusation and that a defendant is presumed innocent until proven guilty.

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MEDICARE UPDATES GUIDELINES FOR REFERRAL OF PATIENTS FOR X-RAYS BY CHIROPRACTORS

A chiropractor, licensed or legally authorized by the state or jurisdiction of service, may provide treatment only in the form of manual spinal manipulation to correct a subluxation (provided such treatment is legal in the state where it is performed). Specifically, Medicare defines chiropractors, based on §18601(r) of the Act, as physicians with respect to treatment by means of manual manipulation of the spine (to correct a subluxation) which he is legally authorized to perform by the state or jurisdiction in which treatment is provided. The following article addresses the ordering of X-rays for chiropractic patients. Read more in the Member's Only News Section. If you are not a member, join the NYSCA today and obtain access to the full story above.

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INDEPENDENT MEDICAL EXAMINATIONS (IME) AUTHORIZATION RELOCATIONS

The New York State Court of Appeals’ June 10, 2004 decision in Belmonte v. Snashall affirmed the New York State Workers’ Compensation Board regulations regarding independent medical examinations, specifically the definition of “board certified” contained in the regulations. The regulations define the term “board certified” as a “physician or surgeon who is certified by a specialty board that is recognized by the American Board of Medical Specialties or the American Osteopathic Association.” Please be advised that because the physicians listed below do not currently satisfy the “board certified” requirement in the regulations as they are not certified by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA), their temporary authorizations to perform independent medical exams have been revoked, effective July 1, 2004. Reports of examination conducted through June 30, 2004 are permitted and the physicians entitled to payment. In addition, testimony and/or depositions concerning independent medical examinations conducted through June 30, 2004 may be provided. Revoked Independent Medical Examinations Authorizations Dominic John Belmonte, MD Donald J. Cally, MD Barry Constantine, MD Arthur Dinoff, MD Harvey Fishman, MD William J. Kilgus, MD Jose R. Lopez-Reymundi, MD Lawrence E. Miller, DO James W. Nelson, MD Jay Alan Rosenblum, MD Librada M. Santos, MD Any questions regarding this matter should be referred to the Office of General Counsel at 518-486-7676. David P. Wehner Chairman

NOTICE OF RESCISSION OF REGISTRATION OF IME ENTITY: NORTHEAST MEDICAL EVALUATION & DIAGNOSTIC SERVICES

Effective June 26, 2004, the New York State Workers’ Compensation Board is rescinding the designation of Northeast Medical Evaluation and Diagnostic Services, P.C. as an entity registered to derive income from independent medical examinations in workers’ compensation cases. This rescission is made pursuant to Section 13-n of the Workers’ Compensation Law and 12 NYCRR 300.2 (e). This rescission is permanent. The entity’s address is: Northeast Medical Evaluation and Diagnostic Services, P.C. 900 Merchants Concourse Westbury, New York 11590 On the effective date of this rescission, the entity named above is permanently prohibited from deriving income from independent medical examinations in workers’ compensation cases. Examinations conducted prior to June 26, 2004 are valid. Any questions regarding this matter should be referred to the Office of General Counsel at 518-486-7676. David P. Wehner Chairman

ACA, VCA To Petition U.S. Supreme Court in Trigon Case

ARLINGTON, VA - The American Chiropractic Association (ACA) and the Virginia Chiropractic Association are set to petition the U.S. Supreme Court to hear the federal antitrust and racketeering lawsuit against Trigon Blue Cross Blue Shield after the U. S. Court of Appeals for the 4th Circuit on June 2 rejected a petition to rehear the case. "The actions of the 4th Circuit were not entirely unexpected, since U.S. Courts of Appeal are reluctant to revisit decisions that have been handed down by any panel," said ACA Chairman of the Board George McClelland, DC. "This only strengthens our resolve to continue this important legal struggle and seek justice for our patients and our profession from the highest court in the land - the U.S. Supreme Court." The issues raised in the petition, however, suggest a direct conflict between the decision of the U.S. Court of Appeals for the 4th Circuit and the two decisions of Supreme Court of the United States [Copperweld Corp. v. Independence Tube Corp., 467 U.S. 752 (1984) and U.S. v. Paramount Pictures, Inc., 334 U.S. 131 (1948)], as well as a direct conflict between the decision of the 4th Circuit and a decision of the U.S. Court of Appeals for the 6th Circuit [Nurse Midwifery Assoc. v. Hibbett, 918 F.2d 605]. Both are issues that are frequently examined by the Supreme Court of the United States: (1) a lower court being out of sync with a controlling decision of the Supreme Court, and/or (2) a conflict between two lower courts of appeal requiring refereeing by the Supreme Court to establish which court of appeals decision and reasoning is correct. The ACA cites in its lawsuit that a conspiracy existed between Trigon and the medical specialty societies in Virginia to ensure that patients with musculoskeletal conditions were diverted to medical doctors instead of doctors of chiropractic. A key piece of evidence in ACA's case was the existence of a committee established by Trigon to review low-back guidelines published in 1994 by the federal government's Agency for Health Care Policy and Research (AHCPR) - guidelines favorable to chiropractic - and to recommend appropriate protocols for referring patients to chiropractic doctors. The committee was appointed from a pool of representatives recommended by medical specialty associations from throughout the state of Virginia. No doctors of chiropractic were appointed to the committee and no chiropractic associations in Virginia were given the opportunity to submit names of nominees to the committee. As a result, the committee published guidelines that did not mention the positive effects of spinal manipulation that had been a highlight of the AHCPR report. The committee instead diminished spinal manipulation's value, and in doing so, essentially invalidated a legitimate federal study, according to the ACA. The Court of Appeals found that the committee was an agent of Trigon - not a separate entity - and therefore no conspiracy existed. Instead, the court likened Trigon's actions to a hospital's credentialing "peer review" process - in which a group of medical physicians determines the qualifications of other medical doctors who are candidates for employment. The ACA believes a conspiracy did exist, and it is inappropriate to compare a hospital's credentialing review process to the types of coverage, payment and referral policy making decisions engaged in by Trigon and the selected medical societies. "We want to bring Trigon's harmful and discriminatory practices to an end, but, equally important, we must keep in mind the big picture," added Dr. McClelland. "We must send a strong signal to all who would seek to oppose, harm, or discriminate against us: we will never give up and will always fight back." The ACA and other plaintiffs have 90 days to petition the Supreme Court of the United States for review.

Medicare Service Specific Review of 98941

The NYSCA received the following letter and guidance from the Upstate Medicare Division Contracted Carrier, HealthNow. The letter is self-explanatory. This information is being supplied to you at the request of HealthNow. Please review the attached information and if you have any comments or questions please feel free to contact Barbara Adams, LPET Specialist at the number contained in the letter. Alternatively, you may elect to contact NYSCA’s Medicare Chairperson and CAC representative, Dr. Peter Pramberger at the following telephone exchange: 516-741-2940.

EEOC APPROVES PROPOSAL TO EXEMPT RETIREE HEALTH PLANS FROM AGE DISCRIMINATION IN EMPLOYMENT ACT

WASHINGTON - During a public meeting today, the U.S. Equal Employment Opportunity Commission (EEOC) voted to approve a proposed final rule that would permit employers, under the Age Discrimination in Employment Act (ADEA), to lawfully coordinate retiree health benefit plans with eligibility for Medicare or a comparable state-sponsored health benefit. This common and long-standing employer practice was called into question in 2000, when the U.S. Court of Appeals for the Third Circuit (Erie County Retirees Association v. County of Erie) held that the federal statute requires employers to assure that pre- and post- Medicare eligible retirees receive health benefits of equal type and value. "This rule is intended to ensure that the ADEA does not have the unintended consequence of discouraging employers from providing valuable health benefits to retirees," said Chair Cari M. Dominguez, emphasizing that the General Accounting Office has estimated 10 million retired individuals aged 55 and over count on employer-sponsored health plans as either their primary source of health coverage or as a supplement to Medicare. "Such benefits are provided on a voluntary basis at the discretion of each employer and the Commission is acting to preserve these valuable benefits for retirees." "We know that health benefits are very important to retirees. Our proposal permits the common-sense practice of coordinating employer-provided retiree health benefits with eligibility for other benefits to continue," added Vice Chair Naomi C. Earp. "This rule should be welcome news for America's retirees." The Commission's prior policy, which was rescinded by a unanimous vote in August 2001, had concluded that coordinating retiree health benefits with Medicare eligibility constituted an illegal age-based distinction under the ADEA. A Notice of Proposed Rulemaking published in the July 14, 2003, Federal Register solicited public comments on the document discussed and voted upon today. The approved proposal now will be submitted, under Executive Order 12067, to federal agencies for final review and any comments they may wish to submit. Pursuant to Executive Order 12866, a review at the Office of Management and Budget will follow. After interagency review, a final rule will be published in the Federal Register. Only after all of these steps occur will the rule become final. In addition to enforcing the ADEA, which prohibits age discrimination against workers age 40 and older, the five-member Commission enforces Title VII of the Civil Rights Act of 1964; the Equal Pay Act of 1963; Title I of the Americans with Disabilities Act of 1990; portions of the Rehabilitation Act of 1973; and sections of the Civil Rights Act of 1991. Further information about the EEOC is available on the agency's web site at:

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TRANSCRIPT OF TRIGON ORAL ARGUMENTS AVAILABLE ONLINE

The transcript of the oral arguments presented before the 4th Circuit Court in Richmond, VA, on February 24th by ACA and Trigon are now available on ACA's Web site.

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Veteran Attorney McAndrews Fights for Trigon Appeal Before Three-Judge Panel

ARLINGTON, VA — With his characteristic repertoire of blistering truths and colorful analogies, ACA General Counsel George McAndrews pulled out all the stops Feb. 24 to convince a federal three-judge appellate panel that insurance giant Trigon Blue Cross Blue Shield conspired to discriminate against doctors of chiropractic. During the hearing in Richmond, VA before the U.S. Court of Appeals for the 4th Circuit, McAndrews presented oral arguments laying out the reasons why he believes the case deserves to be sent back to the district court for trial. "Once in a while, everything needs to default to common sense," McAndrews implored the judges. "To say there is no conspiracy here ignores reality." During the hearing, McAndrews and attorneys for Trigon each had a total of 20 minutes to state their cases and respond to questions from the judges. McAndrews used 14 minutes of his time to present evidence that Trigon had altered the federal government's 1994 guidelines on acute low back pain to remove reference to chiropractic-style spinal manipulation — purely for economic reasons. Trigon's new "referral" guidelines, co-authored by representatives of most of the state's medical physician trade associations and medical schools, effectively directed low back patients away from chiropractors and to pharmaceutical treatment by medical doctors, he said. McAndrews then saved his six remaining minutes to use for rebuttal following Trigon's presentation. "They changed the critical definition of manipulation," McAndrews explained. "The evidence is that they weren't trained in [manipulation]. It was panic time." During their 20-minute presentation, Trigon attorneys contended there was no evidence of a conspiracy and that doctors of chiropractic were paid less than medical doctors because they are not as highly educated. According to Trigon attorneys, a for-profit company such as Trigon has every right to make business decisions that it feels make the best business sense. During his rebuttal time, McAndrews challenged the Trigon attorneys' assertion that doctors of chiropractic are less educated and should therefore make less money than medical doctors. McAndrews explained that, while the medical doctors controlling Trigon base their decisions to discriminate against doctors of chiropractic on monetary issues, professional pride also comes into play. McAndrews quipped that medical doctors/M.D.s see themselves as "Major Deities," but they sneer at other professionals with doctoral degrees, including judges and attorneys who have J.D. degrees, as merely "Just Docs" — a statement that elicited knowing chuckles from the judges. McAndrews concluded by emphatically reiterating that Trigon's and its medical physician co-conspirators' actions constituted medical fraud and were based on "pure economic greed." He reminded the court that every person who has ever been mistreated by under-educated medical doctors for musculoskeletal problems and has had to endure unnecessary pain, surgery or work or social disablement from the mistreatment were silent witnesses to this lawsuit. After the hearing, McAndrews had positive comments about the process. "We were impressed by the depth of knowledge shown by the panel," he said. "It is clear that they carefully read our briefs and were prepared to ask knowledgeable questions about the legal conflict that exists between medical doctors and chiropractic doctors. They questioned both sides fairly and I can only hope that common sense prevails. It appeared that the court was very bothered that the chiropractic doctors were left with no apparent recourse or remedy for a rather apparent series of wrongs perpetrated by Trigon and its co-conspirator medical trade associations." A full courtroom — with many supporters from the chiropractic profession — was on hand to witness this historic event. In addition to McAndrews' legal team, spectators included ACA President Donald J. Krippendorf, DC, ACA Chairman George B. McClelland, DC, ACA Executive Vice President Garrett F. Cuneo, ACA Legal Counsel Tom Daly, ACA Media Spokesperson Jerome McAndrews, DC, Former ACA Chairman Louis Sportelli, DC and ACA Vice President of Communications Felicity Feather Clancy. A decision about the case from the appellate court could be rendered within one to six months after the oral arguments. For a full copy of the appeal brief, click here. In addition, a full transcript of the Feb. 24 oral arguments will be available on ACA's Web site in approximately one week. The National Chiropractic Legal Action Fund (NCLAF) has been established to support ACA's federal chiropractic lawsuits on behalf of the profession. Doctors, patients and other concerned individuals may contribute to the fund by making a donation online or sending a check to NCLAF, P.O. Box 75359, Baltimore, MD 21275.

Growing medical costs seen as No. 1 workers comp trend

BOSTON (Nov. 10, 2003)-The most important nationwide trend affecting workers compensation this year has been increases in medical costs, according to panelists speaking during the recent Business Insurance's Workers Compensation and Disability Management Conference. This "most critical" trend means that the cost of caring for injured workers' medical needs is now a larger part of each workers compensation claim dollar, said Nancy Schroeder, assistant vp-workers compensation for the National Assn. of Independent Insurers in Des Plaines, Ill., who addressed the conference late last month in Boston. According to data from the National Council on Compensation Insurance, "medical claim costs are alarming, with double-digit increases the last two years. In 2002, medical severity increased by 12%, even greater than the 2001 increase of 10.7%." Yet it is important to remember that comp care "represents only 3% to 4% of total health care expenditures," said Keith Bateman, vp and director of the Alliance of American Insurers in Downers Grove, Ill. Several factors contribute to the increasing health care costs of workers comp claims, Mr. Bateman said. While costs are up for inpatient hospital stays and specialists' fees, the increased cost and utilization of prescription drugs makes that the key contributor, he said. What's particularly troublesome for workers comp insurers is that many of the tools available to control drug spending in group health plans, such as worker co-payments and the ability to direct an employee to a particular pharmacy, are not available to them (BI, Oct. 20). In addition, employers and insurers are grappling to cope with the growing use of the painkiller OxyContin. The drug, which was originally intended for people suffering from severe long-term pain, has become one of the most popular drugs prescribed for workers comp claimants. The concern with the drug stems from its addictive nature and how some users are abusing it. Some claimants who use it become addicted while recovering from their injuries and then must go through a detoxification program before they can return to work, Ms. Schroeder said. In addition, the slow-release medication can produce a heroin-like high when consumed after being ground up. It has a street value of 10 times its cost, which may entice some workers to make money by selling it, Ms. Schroeder said. But rising medical costs are not the only national trends that have emerged this year, Ms. Schroeder said. Another trend concerns federal impingement on state workers comp programs, she said. That "is an increasing and disturbing trend," said Bruce C. Wood, assistant general counsel with the Washington-based American Insurance Assn. One of the most serious examples of that is the federal Medicare program's "far more aggressive stance" in protecting its status as "the secondary payer" of benefits to previously injured workers, he said. Consequently, Medicare is requiring employers to establish trust funds to pay the medical costs of older injured workers to help ensure that employers and their workers comp insurers primarily pay such costs, so that they are not left to Medicare, he said. The Medicare secondary-payer issue "has been increasingly disruptive" and is expected to continue because Medicare is going broke at the same time Congress is expanding the drug benefit Medicare offers under its program, Mr. Wood said. Lobbying efforts heretofore have not resolved the problem, so the next step is to get Congress to step in and define Medicare's appropriate interest in a state-based workers comp system, he said. Another example of federal impingement is a bill (H.R. 1562) approved by the House Veterans' Affairs Committee that could allow veterans to receive medical care for workers compensation claims through the U.S. Veterans' Administration. It also would permit that entity to recover full charges for any such medical care, which could increase workers comp costs, Mr. Wood said. Despite those infringement issues, some progress has been reported in resolving workers comp payers' concerns about their continued access to claimants' medical data, following enactment of the Health Insurance Portability and Accountability Act earlier this year. Payers need access to such data to resolve claims and had been concerned that physicians might respond to the privacy requirements by denying information to them, although the law's preamble expressly excludes applying those provisions in the case of workers compensation claims, Mr. Wood said. While there have been pockets of problems, the education effort appears to be succeeding, Mr. Wood said. Another national trend concerns various types of activity involving state-specific funds, which generally exist at least to provide a source of workers comp coverage, if none is available elsewhere. Developments this year include concerns about the solvency of the competitive California state fund, which, if declared insolvent, could "take down" private insurers linked to it by guaranty funds, Mr. Bateman said. Meanwhile, the Arizona state fund is suing legislators who sought to use its accumulated assets for general expenses, he said. In several states, though, there have been proposals to allow a fund to write others lines of insurance, such as medical malpractice insurance in Oregon, he said. Finally, workers comp insurers continue to be concerned about state funds that seek to write workers comp insurance outside their borders while still maintaining their federal tax exemption, he said. That exemption reduces their cost of operation relative to their private insurers, who have complained that their entry into the marketplace constitutes unfair competition. This information is reprinted with permission of the Business Insurance. Copyright 2004. To learn more visit Business Insurance website:

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