Insurance Key References

Following is a list of links to various publications with helpful information on insurance filing guidelines and requirements.  At the bottom is a convenient downloadable document with all of this information listed.
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Wisconsin Worker’s Compensation Treatment Guidelines DWD CH 81.04
https://docs.legis.wisconsin.gov/code/admin_code/dwd/080_081/81

General. Except as set forth in par. (b) and s. DWD 81.04 (5), a health care provider may not direct the use of passive treatment modalities in a clinical setting as set forth in pars. (c) to (i) beyond 12 calendar weeks after any of the passive modalities in pars. (c) to (i) are initiated. There are no limitations on the use of passive treatment modalities by the patient at home. DWD 81.06(3)(a)

Wisconsin Worker’s Compensation Tx Guidelines Departure from Guidelines / Exceptions
DWD 81.04(5) (5) Departure from guidelines. A health care provider’s departure from a guideline that limits the duration or type of treatment in this chapter may be appropriate in any of the following circumstances:

Wisconsin Unfair Claims Settlement Practices
Ins 6.11  Insurance claim settlement practices.https://docs.legis.wisconsin.gov/code/admin_code/ins/6/11/3

Wisconsin Medicaid CMS1500 Claim Instructions
https://www.dhs.wisconsin.gov/forms/f0/f01234a.pdf
https://www.forwardhealth.wi.gov/kw/pdf/2008-89.pdf

Wisconsin Medicaid – New Requirements and Clarification of Chiropractic Services
https://www.forwardhealth.wi.gov/kw/pdf/2016-35.pdf

Documentation, SOI, 20 visit limit, exam clarification.
State of Wisconsin Insurance Equality
632.87(3) Wisconsin Insurance Equality Chiropractic

Medicare Supplement Mandated Benefits Wisconsin
https://oci.wi.gov/Documents/Consumers/PI-002.pdf
Medicare Supplement and Medicare SELECT policies cover the usual and customary expense for services provided by a chiropractor under the scope of the chiropractor’s license. This benefit is available even if Medicare does not cover the claim. The care must also meet the insurance company’s standards as medically necessary.

Wisconsin Provider Manual Anthem BCBS
https://www.anthem.com/docs/public/inline/PM_WI_00006.pdf

Wisconsin Anthem BCBS Commercial Reimbursement Policy
https://www.anthem.com/docs/public/inline/C-08010.pdf

Wisconsin Anthem BCBS Commercial Modifier Rules
https://www.anthem.com/docs/public/inline/Modifier_Rules_2021.pdf

Downloadable Reference Guide: Insurance Key References

Anthem Chiropractic Network Reductions

(Wisconsin, April 4) Chiropractors in WI received certified letters from Anthem BCBS announcing that they are initiating a sweeping reduction of their chiropractic provider network to supposedly “right size their provider network as a result of the ACA”.

According to Mr. Dave Michel of Petty, Michel & Associates, if you have one of these letters, you’ll be removed from the BX network on Sept 30 “without cause”, as allowed under your provider agreement.

He says that it looks like they may be targeting larger clinics in each city with higher utilization and also possibly those with a focus towards wellness,and that this doesn’t bode well for their customer base.

Dave mentioned that a similar tactic was used by insurance companies in Massachusetts with the introduction of “Romney-Care” in 2006 and after the hue and cry, chiropractic offices continued to grow. This has also been the case with offices that we have worked with when the doctor was booted from a network – stats go up!

In many cases, the out of network benefits are close to those in network.

Dave has written a letter that you can customize and send to your patients should you get hit by an insurance company claiming they need to “right size.” You can download a copy of this letter as a Word file with the link provided below.

A key to survival is patient education, not only on chiropractic, but also on chiropractic benefits. This is why we stress the Patient Financial Consultation, or the Post Report of Findings.

Lastly,  Dave recommended working together as a group with your state associations and respectfully confronting any insurance company that discriminates against chiropractic services with the facts.  And the facts are that chiropractic care doesn’t cost… it pays.

While you may not practice in Wisconsin, there may be a time when you receive such a letter and if you  do,  these suggestions  can help.

For PM&A clients, if you have received a letter like this, let us know and we’ll work with you on your options.

Sincerely,

Ed

Dave Michel’s Letter to patients: Anthem Termination Letter