12 I Summer 2018 www.anjc.info Insurance Update MEDICARE Q&A SHBP $35 OON Cap Lawsuit: On April 25, the New Jersey Superior Court Appellate Division issued a decision in the State Health Benefit Plan $35 cap on out-of-network chiropractic reimbursement appeal. Unfortunately, the decision is not in our favor. The court ruled that a 2011 amendment to the SHBP statutes gave the commission unbridled discretion to change the plan benefits, including capping out-of-network reimbursement for chiropractors. Needless to say, the ANJC disagrees with the decision and feels that it is inaccurate as a matter of law. With the approval of the ANJC’s State Board of Directors, ANJC General Counsel Jeff Randolph has appealed this decision to the New Jersey Supreme Court. The appeal was filed on Thursday, May 10th. Unlike the Appellate Court, the Supreme Court does not have to hear all cases presented. Generally, the decision on whether the case will be accepted or not is made within 60 days of filing. As such, we anticipate notification by the end of July. As those of you who have been in practice for some time recall, the ANJC had to follow the same route to the Supreme Court in the Bedford matter where chiropractors lost extra-spinal manipulation for over a year. We won the case at the Supreme Court and will do all that can be done to prevail in this case as well. Horizon 98943: Since the beginning of the year, the ANJC has heard from many members that CPT code 98943 is being denied on various (but not all) Horizon plans. The denial reason code has been U702: “This service is not paid. This denial occurred because the procedure code has a status indicator of N, I, P, M, R or C. Refer to the Medicare Physician Fee Schedule to determine CMS Guidelines for reimbursement.” As previously reported, we reached out to Horizon management on this matter. They were aware of the issue and planned to correct the systemic issue causing the denials, then to issue payment on the denied 98943 claims. Horizon fixed the system issue causing the denials at the end of April. They advise that the issuing of corrected payments for previously denied 98943 claims will begin July 16th and could take 4-6 weeks to complete. If you have not received all corrected payments by the end of August or you receive new, erroneous denials of 98943, please contact me at matt@anjc.info. Data iSight: We have heard from many members that they are having out-of-network claim payments reduced by a group called Data iSight. Data iSight is a reprocessing entity owned by MultiPlan. So far we have mostly seen the reductions on out-of-network CIGNA claims. However, recently they have shown up on other plans as well, including some United Healthcare products. Unlike more common “fee negotiation” tactics, these are not letters or faxes requesting the doctors to accept a reduced fee. These are EOBs that simply apply a reduction as if the doctor is in some kind of network or has a contract with this Data iSight when in fact they do not. The EOB shows the patient has a very low or zero balance, and in the very fine print, the EOB says you cannot balance bill the patient if you accept the allowed amounts and to call Data iSight before billing the patient. Results from when doctors have called have been mixed, but in most cases Data iSight has held firm to their re-pricing and directed the doctor to speak with CIGNA. CIGNA in turn sends the doctors back to Data iSight. Nearly all CIGNA plans in New Jersey are self-funded and hence under ERISA law. As such, complaints regarding these plans will not be accepted by NJ DOBI. The Employee Benefits Security Administration (EBSA) is the department within the U.S. Depart- ment of Labor which is responsible for enforcement of ERISA law. You can contact or file a complaint with EBSA at https://www.dol.gov/agencies/ebsa/ about-ebsa/ask-a-question/ask-ebsa. All self-funded plans are ultimately governed by a document called the Summary Plan Description (SPD). This document is the “fine print” of these plans. This document should describe in detail the process by which out-of-network plans are to be paid under the plan as opposed to an arbitrary reductions by a third party. Any plan participant has a legal right to this document under ERISA law and a carrier or plan sponsor that denies the request can be fined $100 per day until the request for the SPD is met. It can be different for each plan sponsor but a human resources representative would be the best way to make this request. Obtaining the SPD would provide the specific language of the plan to refute Data iSights reductions and rebuke the misleading narrative that the doctor is overcharging the patient when in fact the plan is underpaying its obligation for the patients care. We are looking for any examples of member experiences with this claim issue. If you have received these reductions please reach out to me at matt@anjc.info. By Matt Minnella ANJC Director of Insurance & Regulatory Affairs 2018 SUMMER INSURANCE UPDATE