Chiropractic and Physical Therapy Practice Benefits

This summer, CB&C, Inc. has again been working with Horizon BC/BS on issues that will help, not just our Chiropractic & Physical Therapy providers, but every provider that submits claims to Horizon BC/BS. The following is a summary of some priority issues.

• Secondary Claim Submission & Payment—secondary payment is inconsistent and incorrect and providers receive payments for sporadic dates resulting in unnecessary phone calls and resubmissions!
• Horizon BC/BS Secondary to Medicare—this is a huge issue for Chiros!
• FEP (Federal Employee Program)—BC/BS Reps often misquote this benefit when providers call!
• CPT 98943—payment is being denied by States such as Illinois, Michigan, & South Carolina.
• Better Call Center Service—don’t we all have complaints about dealing with the call centers?

I know there are some larger fights being fought between the Chiropractic Community and Horizon BC/BS regarding their policy on physical therapy modalities – and we support those efforts! However, the issues above also greatly affect provider reimbursement, not to mention the cost of paying employees for time better spent elsewhere. Let’s also mention the obvious stress and aggravation that accompanies these issues.

Through many meetings, we are working hard with Horizon BC/BS to implement improvements in the following areas:

Secondary Claim Submission and Payments
We have provided many many examples to Horizon BC/BS as proof that their current processing system of secondary claims is not as accurate as it should be. They are looking into how they can better improve their procedures to reduce the work of providers and Horizon BC/BS alike.

Horizon BC/BS secondary to Medicare
When consulting, we find a tremendous amount of money is lost when Medicare is primary and a carrier, such as Horizon BC/BS is secondary. First, we find that billing is often done incorrectly as offices do not explore thoroughly what type of ‘secondary policy’ they are dealing with (typical classifications—Supplemental Policies, Secondary Polices, or Carve-out Policies). In addition, the use of the proper modifiers is imperative to obtain proper denials from Medicare. This topic in-and-of-itself can be an entire article in this publication. Offices can call us at 973-827-3544 with questions about proper billing and policy identification!

After the type of policy is identified and proper billing has been done, many offices assume (and rightfully so) that if the Medicare EOB indicates the claim has been forwarded to Horizon BC/BS (for example), there is nothing else to be done. This is not necessarily the case. Medicare crossovers are usually only for the charges paid or applied to the deductible—NOT for charges correctly or incorrectly denied. When the Medicare EOB lists the ‘PR__’ denial for the 98943 for example, (indicating ‘patient responsibility), that is payable by Horizon BC/BS. Providers assume that since the Medicare denial is accurate and since the claim was directly forwarded from Medicare to Horizon, there is nothing for the provider to do but wait to get paid—NOT SO!!! Providers currently still have to hard copy and submit that claim and EOB (with denial codes) to Horizon BC/BS for proper reimbursement. How many providers get the first EOB from Horizon that pays the patient responsibility on the 98940— 98942 but denies the 98943 and they accept that they will not be paid from Horizon BC/BS? – TOO MANY!! We would like to see BC/BS pick up all information in that crossover procedure! Shouldn’t it be that Horizon BC/BS promptly processed the 98940—98942 AND 98943 the first time? This is what we are working with Horizon BC/BS to accomplish!

FEP (Federal Employee Program)
Based on our persistence—Horizon BC/BS is retraining its employees in this department to quote these benefits accurately. Chiropractic offices should know they ARE entitled to be reimbursed for physical therapy modalities on these patients but ARE NOT able to be paid for CPT 98943.

CPT 98943 and States such as Illinois, Michigan, & South Carolina
We have again identified States that are not reimbursing CPT 98943 to Chiropractors, even though the claims are being properly sent to Horizon BC/BS for pricing and then forwarded to the home plans. These States are again claiming that CPT 98943 is not covered in their State and therefore they will not reimburse NJ providers for it either. Horizon BC/BS has again teamed with us to request these States to correct their processing systems for NJ providers. Each BC/BS carrier is responsible to honor the State’s contract IN WHICH THE TREATING PROVIDER PRACTICES!. After all—isn’t that the exact reason providers are instructed to submit the claim to the local BC/BS for re-pricing and participation status information!

Horizon BC/BS has reached out to their contacts in these States and is working on this issue. We feel it will be resolved just as Empire BC/BS inevitably corrected their processing system for NJ providers! We at CB&C, Inc. feel strongly that NJ Providers (contracted with any of the BC/BS products, including Traditional) are entitled to be paid for CPT 98943.

Better Call Center Service
We have been working with a team of Horizon BC/BS executives in hopes of improving this issue. As a team, they are tracking our phone calls, pulling tapes of our conversations, etc. to improve quality. We are emailing information from any call that does not end in a desired result-and Horizon BC/BS is listening! We are all trying to be patient in regards to an outcome!

As stated—these issues are each individually small, but together THEY ARE OMINOUS! Thanks for everyone’s responses and support—keep up the good work and we will keep you posted!

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