The News:
The American Chiropractic Association (ACA) has filed a nationwide class-action lawsuit (Solomon v Anthem, et al) against ACN Group Inc, alleging that ACN participated with other managed care companies in a conspiracy to illegally underpay providers by denying reimbursement for medically necessary treatment. The complaint states the defendants, including ACN, refused to compensate health care providers for covered services; processed health care providers’ claims using either automated programs that manipulate standard coding processes or use unqualified personnel to determine whether or not the service provided was medically necessary and covered; down-coded and bundled legitimate claims to less costly procedures; refused or reduced payment for certain categories of treatment; failed to recognize valid assignments of benefits; and delayed payments to health care providers by requesting additional documentation, even when such documents should not be required.

Your Views:
Sharon Ihlefeld, DC, Los Gatos, Calif, said, “I do believe ACN has denied payments and/or underpaid providers for chiropractic services. I have a patient who has been coming to me for chiropractic care since 2002. Until January 2005, she was covered by Great West Insurance. The payments I received from Great West were timely and fair. In January of 2005, Great West merged with ACN. I was never even informed by them that there was a merge. I began receiving denials for my claims; the reason was that I was filing my claims to the wrong office. It wasn’t until I called several times that I was finally told about the merger. At that point, I began submitting claims to ACN. When I didn’t receive payment over the course of several months, I went through more hoops, calling ACN to find a correct address. No one knew where my claims were. I had submitted them several times. I finally received confirmation that ACN had received a claim from me, by way of an explanation of benefits denying payment due to timely filing. I was told that because I had submitted a claim that was for treatment over 90 days past, the payment had been denied. I had to waste hours disputing the claim as the reason a claim hadn’t been submitted timely was because ACN had failed to notify me of the change of insurance provider for the patient, and due to the fact that I had been given as many as three incorrect mailing addresses to submit claims. After another 3 months, I finally received payment and found that the payments I now receive from this patient’s insurance was cut in half compared to what I received from Great West in the past. I am currently working out a cash plan with the patient as I don't intend to be a provider for ACN due to their business practices.”

Steven Zaeske, DC, DABCI, Orland Park, Ill, said, “I must applaud the ACA for their action on this matter. I have experienced ACN’s antics firsthand, and I am glad to see the ACA is addressing the issue. The big issue here, in my opinion, is whether we are going to insist on being treated as legitimate physicians by the insurance companies or let them subjugate us to second-class status. It will take more than lawsuits for us to be recognized as legitimate, of course, but it is certainly appropriate to take action when needed.”

The News:
The American Medical Association (AMA) House of Delegates adopted a resolution to study and publish a report on the qualifications, education and licensure, and certification requirements for all limited-licensed practitioners, including chiropractors.

The AMA has announced the formation of a Scope of Practice Partnership (SOPP), which plans to fund studies that determine whether “allied health professionals” fill health care voids in rural and other underserved areas. SOPP will also examine the education and training of such “allied health professionals” to create a “point of comparison” for legislators.

The American Chiropractic Association is uniting with other health care provider organizations to publicize that SOPP's actions will impede, rather than enhance, patient access to quality care.

Your Views:
Matthew Roller, DC, Sandy, Utah, said, “I feel that scope of practice should be determined as problems arise, starting with broad scope that should be determined by the education of the provider, and limiting it down as problems arise. I don't feel that one profession should determine the scope of another. The AMA has a history of anticompetitive practices, and I can see this as a potential to continue that practice.”

Bart Wetherington, DC, Savannah, Ga, said, “By the AMA doing this ‘study’ on the qualifications, education and licensure, and certification requirements for all limited-licensed practitioners, it will only make us look better. The American people, government, and all others involved will see right through the true intentions of the AMA, which is trying to eliminate any competition, not help their patients.”