Managed Care & Insurance Committee Updates

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[UPDATE] From CalChiro’s Managed Care & Insurance Committee Regarding January 2020 Meeting
January 23, 2020

The Managed Care & Insurance Committee held its monthly meeting to discuss health plan issues and initiate the scheduling of meetings with stakeholders including legislative staff/consultant members, Surgeon General of California, and health plan representatives. Discussion regarding coalition building to add strength and numbers to issues of concern in 2020 was entertained.

The Governor has created two entities – Health California for All Commission, and the Office of Health Care Affordability. CalChiro representatives will attend meetings and participate in public-policy discussions for both entities. It is anticipated that information hearings on the expansion of the Essential Health Benefits definition will occur in the next several months. It is not yet certain if provider groups will be invited to submit oral testimony, but certainly CalChiro will be available in that regard and certainly will provide written testimony. The expansive definition is important as CalChiro will advocate for the inclusion of doctors of chiropractic as a category of provider – particularly in the Covered California program.

CalChiro has received from members issues related to E/M code use, adjudication of claims of Medi-Cal beneficiaries (particularly in those members whose benefits are managed by a delegated entity), access to doctors of chiropractic by children (typically under 4 years of age), and adjudication of 3rd party liability claims.

As always, documentation received by CalChiro members related to denial of claim submission, or issues that appear discriminatory are welcomed by the association.

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[UPDATE] From CalChiro’s Managed Care & Insurance Committee Regarding Advocacy Activities for 2020
January 9, 2020

The Managed Care & Insurance Committee (MCIC) will continue its advocacy activities with stakeholders that either manage services provided by doctors of chiropractic, regulate the health plan industry, as well as other public policy decision-makers. Currently, we have request letters to Cigna and Blue Cross on a variety of issues related to coding and denial language of services, and Blue Shield on the delegation to ASH for services providers to select Blue Shield PPO markets. It should be noted that according to Blue Shield, not all PPO plans will be managed by ASH, and therefore, those Blue Shield-contracted providers should retain their contract status. There remain several outstanding issues from 2019 related to ASH policy/procedures, and we will engage with their leadership on these matters, including some provider confusion related to the Blue Shield/ASH delegation issue.

As we have noted previously, the MCIC will continue our meetings with stakeholders regarding Covered CA. Recently, the Governor created the Health California of All Commission. CalChiro will be in attendance at each meeting and offer information relative to the inclusion of the chiropractic profession’s participation in crafting health care policy. Of interest is several of the commission members, legislative appointees, and ex-officio members have a long history with CalChiro, including presentations to CalChiro conferences and meetings as well as assisting in legislative activities.

January is a particularly challenging time of year related to full service health plans and the delegated entities that manage certain benefits. These challenges include, but are not limited to eligibility determination and verification of benefits, including deductibles. As we have stated previously, CalChiro cannot advocate on behalf of each provider. However, certainly if a global issue is identified that adversely effects all CA-based doctors of chiropractic, CalChiro should be notified and we can initiate discussion with the health plan, or its’ delegated entity. If resolution is not available at that level, presentation of documents and in-person meetings with regulatory personnel will be scheduled.