Managed Care and Insurance Relations

The Managed Care and Insurance Relations Committee reviews and researches answers to questions and concerns of members regarding managed care issues and give guidance based on practice experience and expertise as to correct coding and billing requirements. This committee meets with insurance companies to discuss member concerns and help physicians as a group have fair and equitable reimbursement for services rendered.

As part of this commitment, the committee will continue to meet with the major medical insurance carriers. If you or any other member physician has an issue that needs to be brought to our attention, please contact us through NJAOPS or email the committee, and we will work on your behalf to resolve or clarify the issue.

Progress Report

April 2016
Members of your Managed Care and Insurance Committee, the executive committee, and the AOA have worked together to help update Horizon Blue Cross Blue Shield New Jersey (HBCBSNJ) policy on manipulation. The new policy currently in effect is much more Osteopathic physician friendly than the one originally submitted last July. The revised policy is far from perfect, but it does represent a step in the right direction and a place were we can continue to work with the state's largest payer on behalf of our members and the patients we all serve.

The current policy allows physicians to bill for both an E&M code as well as an OMT code during each visit (providing the documentation supports both). It will be up to each member to be sure that they are aware of the elements needed to code at proper levels. The original bill would only have allowed an E&M code on the first visit, with a significant change in the patient symptoms, or after 30 days of treatment. Additionally, the original policy questioned the validity of submitting an OMT code with a modifier 25 and an E&M in the first place. Through diligent education and assistance from the AOA (including President-Elect Boyd Buser, DO) we were able to get a policy that allows our physicians to treat patients as we were trained, by identifying somatic dysfunction during an examination and then treating via OMT.

Key to moving forward will be the responsibility of all our physicians to be familiar with and use proper coding when reporting E&M care, and being sure the chart clearly documents the level of care being billed. A separate Osteopathic Structural examination should be present to identify Somatic Dysfunction, and a note documenting the treatment rendered.

The policy still requires physician notes to be submitted for all level 4 or 5 visits when coupled with an OMT code. This is something we hope to continue to work with Horizon on in the future, to remove this added burden from our physicians who have shown their coding passes an E&M audit. We will continue to inform you our members should the policy change and encourage you to reach out to us any time you find you are having issues with the payers.