Managed Care & Insurance Committee Meeting Update


The Managed Care & Insurance Committee (MC&I) met on May 21, 2020 and the following are highlights of that meeting. The Weideman Group gave an overview of the current legislative and regulatory environment. For all intents and purposes, the budget shortfall due to response to COVID-19 is front and center with legislative activities essentially limited to COVID-19 issues and health insurance coverage, including Medi-Cal. CalChiro continues to offer input to the legislative process and regulatory agencies in this environment, particularly as it relates to non-payment of telehealth services and other issues that may arise caused by the COVID-19 pandemic. For example, legislation to capture data by health plans, including specialty health plans (like ASH Plans). CalChiro has met with the author on the importance of data collection from specialty plans as this information may assist CalChiro in future legislative discussions on the cost savings associated with the inclusion of doctors of chiropractic as a category of provider, and the number of members in a health plan with a “chiropractic” benefit. The members of the MC&I Committee offered information related to the impact the pandemic has had on their practice, including increased costs associated with PPE requirements, practice hours, and patient issues.

The ASH Professional Affairs Healthcare Advisory Committee (PAHAC) met on May 22, 2020 and two CalChiro representatives attended the meeting. The composition of PAHAC includes, but is not limited to, national and state chiropractic associations, chiropractic colleges, American Public Health Association, ASH contracted providers, and non-contracted practitioners. The following are highlights of that meeting:

  • Network adequacy remains strong. ASH does not currently see any reduction in contracted providers. They have received input from approximately 100 doctors of chiropractic nationwide (24,000 contracted providers) indicating significant challenges related to their office remaining closed and re-opening.
  • ASH work force includes 95% remote workers; 50% reduction in calls; 30-40% reduction in other areas (claims, medical necessity review). ASH has not encountered any access issues related to their contracted providers to date.
  • Telehealth issues – many health plan clients were pro-active (Cigna) in paying claims for telehealth services provided by doctors of chiropractic. To date, most health plans have required doctors of chiropractic to bill E/M codes with modifier (to ID telehealth services). Some plans will expand their payer summaries to reflect telehealth services. With respect to the concern to the use of E/M codes and ASH limitation on those services, MNR review will remain in place with the tier level assigned to the provider.
  • ASH is reviewing fee schedules currently in place as well as cost-sharing for COVID-19 specific services. ASH has communicated with its contracted providers to utilize ASHLink (ASH electronic platform) for communication with ASH. Based on the percentage of utilization of ASHLink, the contracted provider will experience reduced (or eliminated) administrative fees, access to the Value Add Program to purchase products/services at a reduced cost, and on-line CEU courses.  With these communications, ASH has noted an up-tick in ASHLink usage.
  • Average contracted provider in CA is 15 years. 41.2% of the CA-based practitioners are in tier 3, with 58% in tiers 4-6. 91.8% of the patients presenting to ASH contracted providers do not require MNR. 4.8% require 1 MNR submission; 3.4% require 2+ MNR submissions. Satisfaction with ASH provider services (use of EB citations, timeliness of TAT for MNR approval, claims payment) is “satisfied or very satisfied. Reimbursement remains a challenge in the <50% satisfaction area.
  • Overall, ASH is responding like other businesses and health plans to review all Executive Orders, legislation and regulatory issues on a state-by-state process and will modify policies/procedures accordingly. There are several initiatives currently in discussion that have been raised by several PAHAC members, specific to their state.

ASH has notified its contracted practitioners that Cigna will reimburse for telehealth services. One of the concerns raised during the PAHAC meeting was that use of POS code 11 was an incorrect code based on the definition of an in-office service. Cigna directed its providers to bill POS 11 as the use of POS 2 will reduce reimbursement. United Health has mirrored that requirement as well. As noted above, doctors of chiropractic are directed (at least by Cigna and ASH as its’ delegated entity, and UHC) to bill E/M codes, with appropriate modifiers. CalChiro has been advised that these requirements are resulting of the inability to re-program claim edits during the pandemic.

CalChiro continues to advise its’ members to submit claims for telehealth services as noted above. If the claim is denied, please appeal the decision, and notify CalChiro through and send the redacted claim (remove patient PHI), however please ensure the denial language is included as well as the health plan and group information. CalChiro is appreciative of the confusion and lack of clarity on the delivery of telehealth services at the claim level and the likely necessity to submit appeals. However, Executive Orders and DMHC requirements are very clear that doctors of chiropractic are included in the category of providers that can bill for these services.