Hot Topics for Chiropractors

7/1/08: Horizon BC/BS - What now?

NJ Chiropractors that are non-participating with Horizon BC/BS should be aware that even though they may be out of network providers, Horizon BC/BS may be affecting their reimbursement unfairly.

Aren’t providers frustrated enough relative to Horizon BC/BS’s chiropractic policy to not reimburse Chiropractors for exams or therapy CPT codes? How about the fact that Horizon BC/BS continues to lower their fee schedule? These two issues are common concerns but really should only be affecting participating providers. That being said, readers of this article should question just how Horizon BC/BS is affecting reimbursement for non-participating providers.

The fact is that non-participating providers should closer evaluate BC/BS EOBs for patient’s insured by BC/BS carriers of other states (like Empire BC/BS or Highmark BC/BS or Anthem BC/BS for example)? Do providers realize that exams and therapy services ARE OFTEN COVERED when rendered by a Chiropractor by many of these BC/BS carriers (dependent on that carrier’s guidelines and the insured’s policy).

That being said, why are such services often excluded when payment is processed to the patient or to the provider? When contacting these other BC/BS carriers to question non payment of these CPT codes, the response seems to be that they are processing the claim according to how the claim was sent over to them by Horizon BC/BS.

Let’s review the claim submission process. Horizon BC/BS is the BC/BS carrier for the State of New Jersey (referred to as the ‘local plan’). There are many other BC/BS carriers servicing the various states across the country (referred to as ‘home plans’). Chiropractic offices often have at least a handful (if not more) of patients insured by a BC/BS carrier other than Horizon BC/BS. This is because patients may live in NJ but work in a neighboring state or a patient may work for a national company and the home offices are in another state, etc.

Both participating AND non participating providers are required to submit claims for these patients to the ‘local plan’. This process allows Horizon BC/BS to advise the ‘home plan’ on whether the provider is participating and if so dictate how the claim should be paid based on Horizon BC/BS fees and guidelines as outlined in the provider’s contract. If a provider attempts to bypass Horizon BC/BS and submit the claim directly to a ‘home plan’, the claim is usually denied or returned stating ‘claim must be submitted to the local carrier’.

Basically, this requirement (for this purpose) seems reasonable relative to Horizon BC/BS participating providers. It only becomes unreasonable when Horizon BC/BS also dictates how non-participating providers should be paid. This should neither be Horizon BC/BS’s responsibility nor their right.

If there is no signed contract between non participating providers & Horizon BC/BS AND there is no signed contract between the patient & Horizon BC/BS, the only function Horizon BC/BS has is to confirm participation status. Horizon BC/BS should NOT impose fees or guidelines dictating how claims should process for non participating providers.

The resolution to this issue is simple. If non participating providers are forced to submit claims to the ‘local plan’ instead of directly to the ‘home plan’, Horizon BC/BS should pass the claim to that BC/BS carrier in such a way to state: This is not a Horizon BC/BS member and also not a Horizon BC/BS participating provider. Please process claims per the patient’s contract and policy guidelines for non-participating providers in your State.

In summary, patients and/or Chiropractors should be reimbursed for any and all services covered per the guidelines of the patient’s BC/BS policy if the provider is not participating with Horizon BC/BS. Period!

For questions or more information, please contact us at 973-827-3544.

10/23/08: Highmark Medicare Services – Time is running out!

Are you prepared for the transition from National Government Services (NGS) to Highmark Medicare Services which is taking place November 14, 2008? While we’ve been advised that it is not necessary to fill out the very extensive applications again, they do require a completed EFT form. With that EFT form, did you include a letter asking to continue to receive paper remittances for those of you who were already receiving and wish to continue receiving paper EOB’s? Please also know that there are forms currently being used that are different than what is being used for Highmark. The good news is the web-site seems to be very user friendly and most of the diagosis codes we are all familiar with in dealing with NGS, seem to be the same with Highmark. To view those forms and all other pertinent information relative to Chiropractic, please visit their web-site @ http://www.highmarkmedicareservices.com/index.html.