Insurance Snap Shots


Lori Grassi WSCA Executive Director and Lobbyist Prior Authorization - Regence


In a recent call with a chiropractor I learned that when you contact an insurer for verification of benefits, it is your responsibility to inquire if the particular plan has a prior-authorization requirement…and if you don’t, the patient visit is your liability! In other words, it is all up to you to ask the right questions. It is all up to you to guess as to what the rules are for each insurer. If you don’t, the visit will be free to the patient. Be sure to educate your staff to inquire about prior-authorization requirements for every patient prior to their visit to assure you will be paid for the care you deliver. Let it be known that I feel this is just one more administrative burden shifted to you and your staff by an issuer.


American Specialty Health (ASH) Comes to Washington through CIGNA


In August, American Specialty Health sent notice to providers that they will be the new benefits manager for chiropractic, massage, acupuncture, and naturopathy for your CIGNA insured patients who are in the HMO, Network, Open Access, Open Access Plus, and POS and PPO benefit plans effective January 1, 2018. The services they will provide are network management, provider contract administration, Medical Necessity Review (MNR), claims processing, eligibility information and benefit services for in-network physical therapists in private practice free-standing facilities. In addition, they will perform MNR services for out-of-network providers as well (but not the claims processing). CIGNA will manage customer services for their insureds. If you intend to join the ASH network, you will need to provide a complete provider agreement no later than October 27, 2017, to be credentialed by January 1, 2018. You can join the network after October 27, but after that date they will not guarantee you will be considered “in-network” by January 1, 2018, and benefits could be denied.


CHP Group (formerly Complementary Health Plans) seeking “Major Payer” in Washington


Washington chiropractors are being contacted by the CHP Group to expand their network of providers while pursuing a contract with a “major payer” in Washington State. The network has stated they are not in a position to share the proposed agreement or fee schedule since there is no contract signed at this time. The WSCA Insurance Committee will meet with CHP soon to discuss how they operate differently compared to other third party entities managing chiropractic benefits for issuers. Providers should request a provider contract and fee schedule before signing any agreement to participate in any network. CHP Group has reported to the WSCA that if you join their network, you do not have to accept every contract they obtain on your behalf-you can select which contracts you are willing to accept and decline others.


Washington Education Association (WEA) Leaves Premera (in most cases)


WSCA learned early this spring that the umbrella organization for the teachers’ unions, Washington Education Association (WEA), would be leaving Premera for the teachers’ health insurance benefits. We also learned that one of the reasons included the complaints by teachers and family members about the prior-authorization requirements by Premera for access to physical medicine and rehabilitation benefits.


Now confirmed by their open enrollment options, teachers have different plans to select from. In some cases, individual education associations are also able to select a plan offered by their respective districts, depending on the terms of their labor agreement. These options could also include individual associations choosing to stay with Premera – which means not all teachers are under the same plan, in select districts.


The WEA is offering plans through Aetna and United HealthCare, where individual districts could be with different insurers (issuer), such as Kaiser or Premera, as an example. Each plan, with each issuer, will have its own benefit limits, access requirements and cost sharing limits. Make sure you don’t assume that all teachers are on the same plan. Make sure that you ask the question, every time, if the plan requires prior-authorization or you could be left liable for the cost of the service(s) after delivering care.


It is all up to you to ask the right questions. It is all up to you to guess as to what the rules are for each insurer.


12 www .chirohealth.org


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