Your Experiences Empower Us

In March 2012, it was reported that the revenues of the chiropractic management network American Specialty Health (ASHN), grew by 17.8 percent, from $155.7 million in 2010 to $183.4 million in 2011. OptumHealth, Inc., another company that provides management services for the chiropractic payer community, recently announced unaudited earnings for the third quarter and nine months ending Sept. 30, 2011. According to Bloomberg Businessweek, the company reported third-quarter 2011 revenues of $1.7 billion, an increase of $577 million from a year ago.

With revenues like these, why is care so restricted by these companies? I believe I speak for the majority of the profession when I say that while no national chiropractic organization, including the American Chiropractic Association, has financial resources that begin to compare to these large networks, we do have the stories of thousands of patients and doctors who describe practices that some would say are abusive and have wreaked havoc on the sacred doctor-patient relationship.

The ACA has a long history of standing strong for the profession in the face of many types of adversity. Many have been in the regulatory and legislative arenas; others, in the legal arena. However, one particular kind of challenge, that of insurance coverage and reimbursement, is one that the ACA has been repeatedly engaged in over many years, with challenges coming from all corners of the health care system. This ever-changing landscape requires the ACA to work collaboratively with insurers, regulators and legislators to obtain the best situation for DCs; to have in-depth knowledge of laws; and when necessary, to strategically develop legal theories that defend adequate patient care.

One of our singular strengths that has helped us throughout all our battles has been the ability to speak out with one voice for the profession. We have played a leadership role in many landmark victories with the help of our members and other chiropractic organizations, such as:

• Medicare policy was changed, removing physical therapists' ability to provide manual manipulation of the spine to correct a subluxation.
• Medicare policy was amended, removing the presumption that MDs and DOs are qualified to provide the chiropractic benefit of manual manipulation of the spine to correct a subluxation.
• For the first time, a chiropractic benefit provision was gained in the Blue Cross / Blue Shield Federal Employee Health Benefit Program, and then later expanded to include physical therapy services.
• Doctors of chiropractic were restored as "physicians" under the Blue Cross / Blue Shield Federal Employee Benefit Program after this status was taken away.
• A policy disallowing cervical chiropractic manipulative treatment was overturned under the Kaiser program when it was presumed this treatment might cause vertebral artery dissection.
• A policy that would have removed the ability of DCs to treat patients diagnosed with headaches and pediatric patients under UnitedHealthcare programs was immediately halted with the collaboration of other chiropractic organizations.
• The restriction by UHC to disallow payment for mechanical traction when performed in clinics was removed.
• Awareness was raised with state Attorneys' General offices and state Departments of Insurance regarding network concerns vital to doctors of chiropractic and their patients, to such a degree that it resulted in many regulatory orders.
• The profession was represented in national, multi-district, class-action litigation on managed care issues against the nation's largest insurers, resulting in separate settlement agreements with Cigna and Humana.
• A first-of-its-kind federal nondiscrimination provision applicable to all insurance policies and all ERISA employee benefit plans (including self-insured plans) was approved, effective in 2014.
• The "spine only" limitation was removed from the AMA Guide to the Evaluation of Permanent Impairment as it pertained to DCs.
• Doctors and their patients are being represented through a national ERISA class-action lawsuit against UnitedHealthcare and Optum (formerly ACN) which brings to light managed care abuses.

All this progress could not have been made without the assistance of DCs who stepped forward to write to representatives, to appeal claims, to notify regulators, and to provide examples of the egregious practices they were experiencing. Few realize that each practicing DC is a steward not only over their patients' care, but also over whether they obtain the coverage for necessary care. With regulators, nothing is more effective at obtaining a remedy than the voice of the patient. As a steward over your patients' experiences – whether a restricted therapy, denied X-rays, an unapproved referral or a downcoded manipulative treatment – you are able to advocate for them.

Currently, some of the ACA's other initiatives to protect the fair, equitable, and timely reimbursement of providers include fighting the following:

• A network that is terminating providers for not holding to per-visit averages of four to six visits per year
• An insurer that restricts patients to one examination per year regardless of a differing condition or exacerbation
• Networks that apply management fees to claims without the patient or provider being notified
• A plan that requires PCP referral in order to have access to a DC
• A network applying restrictive policies contrary to the patient's certificate of coverage
• A plan charging excessive co-pays, creating a phantom benefit
• An insurer that pays patients a stipend so they will disclaim using their remaining PIP benefits
• A network / insurer that requires a provider to participate in one network as a condition to participate in another
• Self-insured employers who only allow chiropractic manipulation to be provided by a MD, DO or PT

The title of this article cannot be overstated. "Your Experiences Empowers Us" refers to the fact that we can do nothing without those who provide us the information and the trust to defend them. It is your experience (what you go through every day) that "empowers" us to fight the good fight, to stay the course, and to see the battle through to the finish for the patients who deserve chiropractic care.

The profession continues experiencing adversity in the area of insurance challenges. While there are presently various battles like the ones above, there is one related to American Specialty Health Networks (ASHN) that has ACA especially troubled due to its potential to affect the care of so many patients and the negative precedent it sets for our great profession. These practices have spread across numerous states and include:

• Not vetting business arrangements through state Departments of Insurance
• Imposing in-network type management upon out-of-network providers
• Not notifiying employers of taking over chiropractic benefit oversight
• Not informing the insurer of their own policies prior to the inception of the contract
• Refusal to notify Medicare of proper routing of claims, resulting in denials
• Lack of clear communication to providers and patients, resulting in coverage errors
• Unwillingness to resolve confusion of patients and providers by coordinating services with insurers
• Restriction of treatment not in keeping with standard chiropractic practice, and lack of appropriate, evidence-based, clinical rationale for denial of treatment
• Interfering with doctors' duty to exercise professional clinical judgment in managing patients' treatment plans
• Disregard of state laws / statutes
• Untimely payment of claims

We now find ourselves in one of those moments in which our profession must once again speak up and be heard! As with all the victories mentioned above, and the challenges we now face, you have the ability to help make a difference. If you and/or your patients are affected by the practices of this company or any other insurance company or network, do not be silent. Contact us and let us know what you are experiencing.

Remember, you are the steward over your patients' experiences. Be sure to give them a voice. To e-mail the ACA's Insurance Relations Department, contact insinfo@acatoday.org. To find out more about our efforts related to this issue, go to www.acatoday.org/cnac.

References

1. "American Specialty Health Announces Historic Growth in Revenue, Membership and New Products for 2011." The Wall Street Journal online (Marketwatch), March 21, 2012.
2. "OptumHealth, Inc. Announces Unaudited Earnings Results for the Third Quarter and Nine Months Ended September 30, 2011." Bloomberg Businessweek (online), Oct. 18, 2011.