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Update on ACA’s Legal Activities

by American Chiropractic Associattion | 11/17/2007 7:57:56 AM

The ACA recognizes and takes quite seriously its traditional duty, on a national level, as protectors of the profession and the patients we serve. In that regard we have, as you know, been engaged in an "all fronts" effort to address the serious threat posed by the practices of certain chiropractic managed care networks and related insurance companies. We will detail, to the extent that we can, the administrative and regulatory actions now under way. We believe we have made significant progress and have initiated a series of state investigations that have resulted in collaboration among many states to make this a national issue. The matter is on the agenda of the National Association of Insurance Commissioners. All of this has the potential of becoming a nationally coordinated investigation by state and federal regulatory officials. We believe we have the facts, the law and the critical momentum on our side. However we now desperately need the follow through of the doctors in the field. Managed care and insurance abuse continues to plague our profession. In over 20 states, the ACA’s legal department and insurance department have visited or otherwise contacted both Attorney General Offices and Departments of Insurance. Many of these contacts have been made with and as a result of the excellent cooperation received from state associations. ACA has been successful in raising the consciousness of these regulatory officials on the problem of managed care and insurance abuses. As a result, the ACA has augmented states’ efforts by providing the national perspective regarding the egregious nature of these issues and that the problems are growing. The message back from these officials has been very clear - if you provide us with the hard evidence of these abuses, we will act and act decisively. ACA has an extensive and active program to collect this type of hard evidence directly from the doctor. Often, our issues mirror those other professions have communicated to them, so our message is connecting and there is now an effort among Departments of Insurance to make this a national effort. A recent effort of DOIs in 36 states against UnitedHealthcare shows the success of such collaboration among regulators resulted in a penalty of $20 million, with an agreement to implement a three-year “process improvement” plan. Failure to meet set benchmarks for appropriate claims payment could result in an additional $20 million fine. ACA has also launched a parallel effort to address managed care and insurance abuse. In addition to collecting information from the doctor in the field, this effort is designed to encourage doctors to file an appeal for every inappropriate denial or restriction of care. We want to exert maximum pressure on the problem by both directly engaging AG Offices and Departments of Insurance and at the same time encouraging a groundswell of appropriate appeals from doctors in order to underscore the depth of the problem. The ACA website has extensive information on how ACA can help doctors file these appeals. It is essential to realize that the solutions to many of our problems are already at hand, we just need the commitment and will to follow through. Both federal (i.e. ERISA) and state statutes are already in place to facilitate aggressive enforcement activities. Now that we have regulators’ attention, they seek more complaints to show how pervasive the problems are in each state and they would like this documentation to follow the channel of direct complaints from patients and providers. Because of our efforts, and those of state chiropractic organizations, regulators now increasingly understand the insidious nature of certain managed care policies and procedures and they are ready to act based on well-documented complaints outlining these abuses. In the case of Maryland’s DOI, officials took an example of one complaint provided by us and directly initiated the investigation process while we were still in their office. You are well aware of our recent data collection of un-sanitized records that began in May. This effort has further opened the door to clarifying that the inappropriate policies used to “manage” chiropractic are, without a doubt, restricting necessary care. As we have indicated, thanks to our combined efforts, regulators now increasingly "get it", and as we respond to their requests to facilitate direct complaints, we are moving to “Phase II” of what is now a three-year intensive effort. We need to mobilize every chiropractor to take the time to exhaust internal appeals for every denial or restriction from insurers/networks and, if not successful, to file DOI complaints so that a massive investigative process can be started that will cross state lines. To assist doctors, the ACA has designed a web pages; provides tools to file successful appeals, and guides the submission of patient files to ACA, and ultimately to regulators. In the coming months we will be identifying key statutes in each state so that doctors can augment their appeals with this information and we will provide more guidance on how doctors can initiate appeals under ERISA plans. Please continue to look for updates on all of these initiatives. Kara Murray Insurance Resources Director Insurance Relations [email protected]


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