Are Insurers Aware of Their Legal Obligations to DCs?
James Lehman, DC, MBA, DIANM
My articles fall under the "ethics" column, but in reality, I attempt to offer information regarding ethical and legal business procedures. Normally, the discussions relate to the behavior of chiropractic clinicians. In this article, let's discuss the ethical and legal business behavior expected from health insurance companies based upon federal law. Hopefully, the chiropractic profession can appreciate this article and realize the potential to improve chiropractic reimbursements for medically necessary and reasonable fees.
Since beginning my chiropractic practice in New Mexico in 1973, I have observed many changes regarding reimbursement by third-party payers for chiropractic services. First, there were reasonable and necessary reimbursements from insurance companies. Then came managed care. The managed care companies often claimed to practice medicine, and frequently generated severe reductions in reimbursement and caused increased administrative costs for providers. Now, we struggle with documentation issues, restrictive guidelines and shrinking third-party reimbursements. When are reimbursements going to improve, if ever?
What Federal Law Mandates
Section 2706 of the Affordable Care Act (ACA), "Nondiscrimination in Health Care," requires that insurers include and reimburse licensed health care providers in health insurance plans:
The ACA nondiscrimination provision states: "A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certi?cation under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures."1
In my opinion, chiropractic physicians must take the bull by the horn if they want to change the current situation. I suggest that DCs should question whether insurance companies are aware of their legal obligations to provide non-discriminatory reimbursements.
According to Section 2706, insurance companies are required not to discriminate against chiropractors; and must reimburse chiropractic physicians at the same rates for the same services as provided by physical therapists, medical doctors, osteopathic doctors, APRNs and PAs. Yes, thanks to the legislative efforts of the American Chiropractic Association, Section 2706 declares there should be no discrimination.
Based upon my discussions with hundreds of chiropractors practicing in the United States, most are unaware of this section in the Affordable Care Act. Yet all of them are complaining of shrinking third-party reimbursements and increasing costs to do business. It doesn't require an MBA to comprehend that reduced revenue and increased costs will produce an extremely negative economic situation for the future of the chiropractic profession.
The Issue of Comparable Value
The major question that must be addressed is the value of chiropractic services. If a chiropractic doctor performs an evaluation and management procedure, does it have the same value as if it is provided by a medical doctor? If both doctors perform the same examination, shouldn't both be of comparable value? According to Section 2706, if the quality or performance measures are the same, the reimbursement rates should be the same for each doctor.
The one caveat that must be considered involves the use of CMT codes. If the chiropractor uses only CMT codes, rather than E/M codes, there can be no comparison with other licensed health care providers who use only E/M codes:
Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.1
The insurance companies are maximizing their profit and returns on investments to stockholders by reducing costs while increasing premiums. Unfortunately, these cost reductions are achieved by reducing payment to chiropractors for services rendered. I refer to this behavior as "economic credentialing," which enables a third-party organization the opportunity to control the growth of the chiropractic profession. The American Medical Association offers the following definition of economic credentialing:
Economic credentialing is a term of disapproval used by the American Medical Association (AMA). The association defines the term as "the use of economic criteria unrelated to quality of care or professional competence in determining a physician's qualifications for initial or continuing hospital medical staff membership or privileges."2
The original name of the Affordable Care Act was the Patient Protection and Affordable Care Act (PPACA).3 Since the law was signed on March 23, 20104 (nearly a decade ago), I wonder why the chiropractic profession seems to be generally unaware of its potential effect on reimbursement for chiropractic services.
What Are We Doing About It?
Are we doing anything to make the insurance companies aware of their legal obligations to chiropractic clinicians for services rendered? I suspect little political activity is aimed specifically at educating the insurance companies of their legal obligation to properly reimburse DCs for services rendered to patients in need of care. After all, it is likely that few chiropractic clinicians, associations or institutions are even aware of Section 2706.
Perhaps some of the stronger chiropractic state associations will seek legal advice and pursue educating insurance companies of their legal obligations to reimburse chiropractors without discrimination. Perhaps a legal suit will need to be filed in order to force the insurance companies to follow this federal law and particularly Section 2706?
Editor's Note: Practitioners and chiropractic organizations / associations with success educating insurance companies regarding Section 2706 are encouraged to share their experiences by submitting a short letter to the editor to editorial@mpamedia.com.
References
Frequently Asked Questions About Section 2706. Integrative Healthcare Policy Consortium.
Economic Credentialing. Wikipedia.org.
Oberlander J. Long time coming: why health reform finally passed. Health Affairs, 2010 Jun;29(6):1112-16.
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