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Dynamic Chiropractic – December 17, 2006, Vol. 24, Issue 26

Horizon Persisting With Its Discriminatory Tactics

Reimbursement for E&M Services Apparently Does Not Apply to DCs

By Editorial Staff

Despite its recent letter to participating providers, Horizon Blue Cross Blue Shield of New Jersey continues to act in bad faith with regard to reimbursing chiropractors for separately identifiable E&M services billed with modifier -25.

According to the Association of New Jersey Chiropractors (ANJC), upon contacting Horizon to confirm the policy applied to all providers, ANJC received conflicting information, prompting the association to request a definitive position on the issue through legal counsel. Horizon responded with a second letter, clarifying that providers who did not previously receive separate reimbursement for E&M services would remain ineligible for reimbursement, despite the new -25 modifier policy.

image - Copyright – Stock Photo / Register Mark "This is clear evidence of Horizon's bad faith and discrimination against chiropractors," said ANJC Legal Counsel Jeff Randolph, Esq., "which has continued since Horizon adopted the chiropractic manipulative codes in the late 1990s. Since then, Horizon has refused to reimburse New Jersey chiropractors for their significant, separately identifiable E&M services, while at the same time paying medical doctors, doctors of osteopathy and other health care providers for the same services. ... Even now that Horizon acknowledges that they have been improperly applying the AMA CPT guidelines by not recognizing the modifier -25, they are perpetuating their discrimination against chiropractors and are creating an even stronger case against themselves for unfair claim reimbursement in violation of the New Jersey Unfair Claim Settlement Act."

As of press time, a ruling is pending from the Administrative Law Judge regarding the E&M issue and three other issues brought before the judge in July 2006: whether Horizon improperly reimburses chiropractors by failing to pay them separately for performing physical modalities on the same day as a chiropractic manipulation; whether the denial of certain services by Horizon constitutes discrimination in violation of state anti-discrimination and insurance equality laws; and whether Horizon's in-network fee schedule for chiropractors, set at 80 percent of Medicare rates, is improper.

The judge is expected to issue his decision to the Department of Banking and Insurance (DOBI) in early December; the DOBI then can accept, reject or modify the judge's opinion. Following that determination, either side can appeal to the appellate division of the superior court within 45 days.

"Even though it would have been nice to have Horizon admit that [it was] wrong and voluntarily agree to pay chiropractors for E&M services, I am actually glad that Horizon has publicly taken such an outrageous position against chiropractors in New Jersey," said ANJC Executive Director, Sigmund Miller, DC. "When New Jersey chiropractors prevail on the E&M issue, Horizon's recent decision to selectively apply its E&M policy by excluding chiropractors will only harm them in the long run. This strengthens our position against Horizon, both with the Department of Banking and Insurance and in the eyes of the public."

Resources

  1. Randolph, Jeffrey. "Horizon Update: Horizon Continues to Act in Bad Faith Toward New Jersey Chiropractors." The New Jersey Chiropractor (a publication of the ANJC), December 2006.
  2. Horizon E&M acknowledgment letter to participating providers, October 2006. www.anjc.info/PDF/EMAcknowledgmentLetter.pdf.
  3. "New Jersey Chiropractors 1, Horizon Blue Cross Blue Shield O. Insurer Agrees to Reimburse for Separately Identifiable E&M Services." Dynamic Chiropractic, Nov. 21, 2006. www.chiroweb.com/archives/24/24/13.html.
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