Action Against Humana in Kentucky Sets Precedent for Other States

The American Chiropractic Association (ACA) has announced that following an investigation of the activities of Humana Health Plan, Inc. (Humana), the Kentucky Department of Insurance identified numerous deficiencies and violations in the insurer's business practices. As a result, Humana was fined $100,000 and is required by the order to take corrective action.

According to ACA officials, this action will set a precedent for other state departments of insurance that may be hearing similar complaints, and it also sends a strong message to health insurers everywhere about the chiropractic profession's willingness to confront unfair practices.

Many of Humana's deficiencies and violations reflect complaints raised by ACA and the Kentucky Association of Chiropractors (KAC), which were based on information provided by doctors of chiropractic in Kentucky. These include:

• subjecting providers' claims to utilization management review based on discriminatory geographic location;
• incorrectly coding chiropractic claims and misrepresenting network and negotiated reimbursement rates;
• forcing providers to participate in all plans as a condition of participation with one plan
• doing business with unlicensed third-party administrators (TPAs) and failing to notify enrollees of the identity of and their relationship with these TPAs;
• improperly denying claims that were sent to Humana instead of to the TPA (providers were inappropriately instructed by customer service reps);
• issuing explanation of benefits statements that were misleading and did not provide a reasonable explanation related to claim resolution; and
• failing to notify the Kentucky Department of Insurance regarding utilization management review policy and procedure changes.

"What's significant here is the ground gained by the chiropractic profession after standing firm and unrelenting in this initiative for the past five years," said ACA President Rick McMichael, DC. "This is a wonderful example of what we can achieve when we work together for a common cause."

ACA's Local Liaison Program, a collaborative network of chiropractic physicians with specialized knowledge of insurance and managed care, played an important role in helping ACA and KAC to collect and prepare information that was presented to the Kentucky Department of Insurance.

In states where reports of similar concerns with Humana have been reported, ACA is contacting other departments of insurance to share this precedent-setting order. Providers with concerns regarding Humana or its use of TPAs should contact insinfo@acatoday.org.

Source: American Chiropractic Association