However, representatives of the professions affected said decisions about treatment should be left in the providers’ hands. The data was reviewed by an independent national consultant, Milliman, Inc., he said.Īmerican Specialty Health will work with care providers in its network to ensure the care they give is necessary and based on their profession’s best practices and the patient’s history, according to Horizon’s information for members. That review would occur only after the patient’s fifth visit, Vincz said, “but in more than 90 percent of cases, there is no review.” Vincz cited Horizon data on claims from 20 that showed chiropractors in the state billed for “more than twice the volume of care compared to national benchmarks,” and physical therapists exceeded national benchmarks by as much as 140 percent for the same period. “Rooting out and eliminating procedures that provide no real medical benefit is fundamental to improving the overall quality, experience and cost of care for our members,” said Thomas Vincz, a Horizon spokesman. Unnecessary or redundant care is estimated to account for about 30 percent of U.S. Spending for back pain - estimated at $86.7 billion in 2013 - includes surgical interventions, imaging studies and prescription drugs as well as physical health services such as chiropractic, physical therapy and acupuncture. Only diabetes and heart disease claim a larger share of the health care dollar. Lower back and neck pain has contributed to those rising costs, because the areas account for a huge and growing chunk of American health care spending. Despite the approach, health care costs have kept climbing. Along the way, there have been many political battles and compromises. Over the years, that approach has extended to nearly every facet of health care spending - from hospital stays to high-priced imaging services and prescription drugs. The conflict brings up many of the arguments first voiced in the 1990s, when managed-care companies began trying to control skyrocketing health care costs by creating networks of doctors, establishing contracted reimbursement rates, and imposing standards to decide whether treatment was necessary and would be covered. 'Loved ones’ lives at stake': NJ residents face uncertainty as Bellwether ousted from 62 group homes NJ news: Fired Passaic NAACP leader had criminal record, lawmaker says Murphy's staff was warned Horizon plans to implement the change on Jan. The state Department of Banking and Insurance is reviewing Horizon’s formal proposal for the new arrangement, to see if the material submitted is complete. Once it is, Commissioner Marlene Caride will have 60 days to decide whether to approve the plan. Horizon says the association has spread false information. Legislators have called the state insurance commissioner to make sure that covered benefits for Horizon members are protected. The association has generated more than 170,000 emails to legislators and Gov. Phil Murphy from chiropractic patients, its spokeswoman said. "This company routinely denies care after just 5 of the 30 visits approved in your plan," the Association of New Jersey Chiropractors has said in a "warning" on its website. With the state in the midst of an opioid epidemic, they say, insurers should be making it easier to receive non-drug-based treatment for pain rather than adding potential hurdles. And they express concern about American Specialty’s reputation. Horizon Blue Cross Blue Shield of New Jersey, with 3.7 million members, says American Specialty Health, based in Indiana, will “make sure you get the care you need, when you need it.” Horizon provides coverage through the state and federal employee benefits programs, large and small private employers, Affordable Care Act plans and individual policies.Ĭhiropractors, physical therapists and others say Horizon's arrangement to have American Specialty review claims will interfere with their ability to provide optimal care to patients and will load them with paperwork. The state’s largest insurer plans to shift oversight of its members' benefits for chiropractic care, physical therapy, occupational therapy and acupuncture to a separate company next year, in a plan that has drawn intense opposition from chiropractors and other medical providers. Watch Video: Chiropractor demonstrates how spinal manipulation can ease pain
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