Humana, Inc., one of 10 managed care companies accused in the Solomon v Anthem, et al., class-action suit of conspiring to underpay doctors of chiropractic and other non-MD providers by denying reimbursement for medically necessary treatment, has agreed, as of press time, to a proposed $3.5 million settlement.1 The settlement will fund payments to chiropractors and other health care providers included in the class-action suit, and cover fees and costs advanced by the plaintiffs' counsel. In addition, terms of the proposed settlement call for Humana to:
The American Chiropractic Association (ACA) participated through counsel in the settlement discussions and is a signatory to the proposed agreement. In addition to the above terms, the settlement stipulates that Humana appoint an ACA representative to the company's newly formed health care provider advisory committee; the stipulation is intended to establish a means of direct communication on any future issues and concerns regarding appropriate reimbursement for chiropractic services.
"We are extremely pleased that Humana has agreed to compensate chiropractors and other non-MD providers for claims that were previously wronged or denied," said ACA President Richard Brassard, DC. "We are heartened that Humana has committed to improving its business practices in the future and are hopeful that other networks and insurance companies will follow suit. Doing so can only benefit the nation's health care consumers, who also deserve fair treatment and reimbursement."
Once the court approves the settlement, the ACA will provide details on how doctors of chiropractic can recover damages. A copy of the entire settlement agreement is available online at www.acatoday.com/pdf/Humana_Settlement.pdf.
Originally filed in October 2003, the Solomon suit alleges that Humana and other managed care companies, including Anthem, Health Net, Aetna, Wellpoint Health Networks, Prudential, Coventry Health Care, and the newly merged United Healthcare and PacifiCare Health Systems, violated the Racketeer Influenced and Corrupt Organizations (RICO) Act by systematically refusing to compensate health care providers for covered services; processing health care providers' claims using automated programs, which manipulate standard coding processes, or using unqualified personnel to determine whether the service provided was medically necessary and covered; downcoding and bundling legitimate claims to less costly procedures; arbitrarily refusing or reducing payment for certain categories of treatment; systematically failing to recognize valid assignments of benefits; and delaying payments to health care providers by requesting additional documentation, even when such documents should not be required.2
In July 2006, the ACA asked the U.S. District Court in Miami to join the plaintiffs in the class-action suit and specifically requested that American Chiropractic Network, Inc., and United Healthcare Services, Inc., be named as additional defendants.3
The ACA's involvement in the Solomon suit is part of an aggressive campaign designed to address and correct managed care abuses. For the past several years, the association has been gathering information from doctors of chiropractic regarding past and current problems affecting patient care and reimbursement, including such practices as automatic downcoding or limiting physician discretion in the planning of care; CPT code bundling; improper utilization review (including refusal to recognize coding modifiers); and performance management issues, such as limiting the number of visits, X-rays and modalities.3 This anti-abuse campaign stems from a March 2002 ACA House of Delegates resolution that formally outlined the association's opposition to these improper practices and authorized the collection of data to determine the specific types of abuses perpetrated by third-party administrators.
In addition to participating in the ongoing Solomon suit, the ACA recently teamed with the Association of New Jersey Chiropractors (ANJC) to challenge the reimbursement practices of Horizon Blue Cross and Blue Shield of New Jersey.4 The issues brought before the Administrative Law Judge on July 13, 2006, include whether Horizon is improperly reimbursing chiropractors by failing to pay them for significant, separately identifiable Evaluation & Management ("E&M") services performed on the same day as a chiropractic manipulation; whether Horizon is improperly reimbursing chiropractors by failing to pay them separately for performing physical modalities on the same day as a chiropractic manipulation; whether the denial of certain services by Horizon constitutes discrimination in violation of state anti-discrimination and insurance equality laws; and whether Horizon's in-network fee schedule for chiropractors, which is set at 80 percent of Medicare rates, is improper.
As of Sept. 16, 2006, the Administrative Law Judge has 45 days to issue his decision to the New Jersey Department of Banking and Insurance, which can accept, reject or modify the judge's opinion. Once the DOBI issues its determination, either side can appeal to the Appellate Division of the Superior Court within 45 days if they are dissatisfied with the ruling.
For more information on the ACA's ongoing legal initiatives against managed care abuses, visit the Chiropractic Networks Online Action Center at www.amerchiro.org.
References
When sports chiropractors first appeared at the Olympic Games in the 1980s, it was alongside individual athletes who had experienced the benefits of chiropractic care in their training and recovery processes at home. Fast forward to Paris 2024, where chiropractic care was available in the polyclinic for all athletes, and the attitude has now evolved to recognize that “every athlete deserves access to sports chiropractic."
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Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
