Health Ins Carriers & MCO's
Aetna - Triad
by Matt Minnella, ANJC Director of Insurance & Regulatory Affairs
Following the ANJC’s successful settlement of our law suit against Aetna for inappropriately denying 97140 codes when billed with CMT, we are still pursuing the fulfillment of Aetna’s obligations under the agreement.
Over the last few months the ANJC has received a number of complaints of X-ray denials for Horizon patients with an unusual reason code. The denials all had a common denial code of F107 which read that the code was denied because, “The modifier is missing or invalid for the reported procedure code.”
As you are aware, the ANJC and an individual chiropractor previously filed suit against the Horizon OMNIA Plan alleging violation of a number of state statutes as well as the Section 2706 of the federal Patient Protection and Affordable Care Act (“PPACA” or “Obamacare”). The basis of the lawsuit was discrimination against chiropractors for placing a disparately high number of chiropractors in Tier 2 of the OMNIA Plan which has high patient cost sharing obligations compared to Tier 1 with lower patient cost sharing when compared to other similar providers such as physical and occupational therapists.
United - Optum
Many of you have received a letter or letters from Optum over the last week or so describing a new “per-visit” fee schedule. Optum has been rolling out this new payment model state-by-state beginning in late 2015. The amount of the per-visit fee varies by state. The $68 NJ per-visit fee is the highest allowance we are aware of thus far.
Cigna - ASHN
On behalf of the Chimicles & Tikellis law firm: Chimicles & Tikellis LLP is investigating whether Cigna is overcharging insureds being treated by physical and occupational therapists (PT/OT) in ASH’s network.