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Table Of Contents
- Two chiropractors and a patient file lawsuit 03/14/11, fully funded by ACS, against Arizona Department of Insurance over refusal to enforce chiropractic insurance equality law. Keep up with all developments on the home page under Breaking News. To read all lawsuit filings and briefs, click here.
- How to File Complaints Against ASH with the Attorney General and the Arizona Department of Insurance
- ASH VP LaBrot Wrote 1990s Treatment Parameter Book Recommending Four Times the Amount of Care Allowed Today by ASH. Read full text in the article posted below.
- Health Insurance Claims and Denials Solutions to get claims paid
- ERISA and Self-Insured Health Plan Solutions to get claims paid
- Did the Relationship Between Former Governor Napolitano and Arizona BCBS Chairman of the Board Robert Bulla Result in Higher Copays for Chiropractic?
- ACS Endorses Practice Guidelines for Frequency and Duration of Care
- How to File a Complaint Over Discriminatory Copays and Deductibles
- Chiropractic Insurance Equality Laws and the 1990 Legislative Position Paper in support including all Circular Letters
- How AAC Member Arlan Fuhr, D.C. and AAC Lobbyist Barry Aarons helped UHC pass a virulently anti-chiropractic bill in 2004 despite the strenuous objections of both the AAC and ACS
- Key Insurance Articles
- ACA v. ASHN and CIGNA: ACA sues ASHN and CIGNA for a wide range of misdeeds. Read the entire lawsuit by clicking here. ACS plans to file the same type of litigation in Arizona.
- National Health Reform Provider Non-Discrimination Provision’s Impact on Health Insurance and ERISA Plans: Click here to read a comprehensive 13 page analysis along with the details of the plan chosen by the Governor as Arizona’s Essential Health Benefits benchmark package for state exchange. Chiropractic coverage includes 20 spinal manipulation and 60 rehabilitation services per year, copay $15.00 per visit.
1. Chiropractors File Lawsuit Against ADOI Demanding Enforcement of Chiropractic Insurance Equality Law
Two Chiropractors and a patient, backed by the Arizona Chiropractic Society (ACS), filed a lawsuit today against the Arizona Department of Insurance (ADOI) alleging failure to enforce the chiropractic insurance equality law, ARS 20-461(A)17 and ARS 20-461(B). This law requires insurers to give patients the option to use their health insurance to see either an MD, DO or DC for neck and back problems and pay the same copays and deductibles with the same overall limitations on treatment. Currently, copays, deductibles and other limitations for chiropractic care discriminate severely against chiropractic care with financial barriers so huge that insurers, led by Blue Cross Blue Shield of Arizona, basically force patients to choose MDs or DOs for back and neck pain. ADOI, despite hundreds of consumer complaints, has refused to enforce this law which only they have the legal authority to enforce. Therefore, this legal action asks the courts to order ADOI to properly enforce the law. Click here and here and here to read the official filed and stamped lawsuit documents. Keep up with all developments on the home page under Breaking News. To read all lawsuit filings and briefs, click here.
ADOI filed a Motion to Dismiss for Failure to State a Claim in which they argued that the ADOI has no duty to enforce the chiropractic law and that it is solely up to her discretion. The Plaintiffs then filed a Response to the Motion to Dismiss. The Court is now considering both motions.
2. How to File Complaints Against ASH with the Attorney General and the Arizona Department of Insurance
To file a complaint against ASH with the Arizona Attorney General, click here for AG complaint instructions.
To file a complaint against ASH with the Arizona Department of Insurance, click here for ADOI complaint instructions.
3. ASH VP LaBrot Wrote 1990s Treatment Parameter Book Recommending Four Times the Care Allowed by ASH
Thomas LaBrot, D.C., the Vice-President of Clinical Services & Professional Affairs, wrote a book about treatment parameters for chiropractic care in the mid-1990s that recommended almost four times more care than he now says is medically necessary as ASH Vice-President. The title was “A Standard of Care for the Chiropractic Profession.” Click here and here to read a full copy of the book. Click here to read the page from the book with the following recommendations for number of visits per condition:
- Mild traumatic 9-17 visits
- Moderate traumatic 19-45 visits
- Severe traumatic 39-68 visits
- Mild non-traumatic 5-12 visits
- Moderate to severe non-traumatic 14-28 visits
ASH is now believed to allow coverage for an average of 6.5 visits per patient episode of care and treatment. These parameters of care are believed to have been developed largely by Dr. LaBrot. There have been no breakthroughs in treatment allowing patients to recover much faster than in the 1990s, and the human body has not improved its ability to heal since that time. The only change since the mid-1990s has been the source of Dr. LaBrot’s income. In the mid-1990s, Dr. LaBrot was an Arizona treating doctor and his income came from delivering treatment to patients. Now, his income comes from ASH which makes more money when less treatment is rendered. Along with the change in source of income came the dramatic reduction in recommended number of treatments per condition.
When ACS goes to court, the key issue will be establishing the generally accepted medically necessary dose of chiropractic care. ASH maintains the number of visits should be in the single digits, i.e., 5 or 7 or 10, for example. ACS maintains that the number of visits should be in the double digits in accord with Chapter 8 of the Mercy Guidelines, the ICA Best Practices and Treatment Frequency and Duration Guidelines, and now even the LaBrot book “A Standard of Care for the Chiropractic Profession.” We agree with LaBrot version 1995, not version 2011. It will be extremely difficult for Dr. LaBrot to explain his departure from his own published standards from the 1990s. This document may be the smoking gun in litigation.
4 -- Fees allegedly above Usual and Customary.pdf: How to protest when an insurance company claims your fees were too high.
5 -- Grievance Letters -- The Best Way to Get Insurers to Pay.pdf: How to use the Arizona grievance law, a powerful tool to bring pressure on an insurer that misbehaves.
6 -- Health Care Appeal Request Form.pdf: There is a legal process when a claim is denied as not medically necessary. This is a sample request form. #7 contains complete instructions.
7 -- Health Care Appeals Process.pdf: A three level process. The third level involves review by an independent party chosen by the Arizona Department of Insurance and paid for by the insurance company.
8 -- How to file a complaint with ADOI against an insurer.pdf: When insurance companies violate laws, complaints must be filed.
9 -- Medical necessity appeal letter.pdf: An excellent general appeal letter.
10 -- Small Claims and Justice Court Instructions.pdf: Sometimes the only solution when an insurance company does not pay is a lawsuit. Here are instructions for suing an insurance company.
11 -- Timely Payment of Claims, Adjudication, Adjustments.pdf: Claims must be paid within a certain time frame, and demands for repayment can only be made within certain guidelines. This document contains the legal details.
11.1 – Timely Payment of Claims, Adjudication and Adjustments.pdf: ADOI Info Brochure.
12 -- ERISA Claims Procedure DOL Rule 29 CFR 2560.503-1.pdf: Key section of the law which you need to know to get results with your appeals.
13 -- ERISA Letter to File an Appeal.pdf: Use this letter today to get results when claims are denied.
14 -- ERISA Letter to Request for a Copy of the Summary Plan Description, Claim Appeal Procedure, EOB.pdf: The first step in an ERISA appeal is to get a copy of the plan document. This is the letter to send.
14.1 -- ERISA Patient Authorization Form.pdf: Your patients must sign this form so that you can file appeals and request a copy of the Summary Plan Description on their behalf.
15 -- ERISA Self-Insured Plans ADOI Letter.pdf: This is the position of the Arizona Department of Insurance regarding ERISA self-insured plans.
16 -- Understanding ERISA.pdf: Complicated subject, simple explanation.
17 -- Understanding ERISA Detailed.pdf: Complicated subject, detailed but understandable explanation.
6. Did the Relationship Between Former Governor Napolitano and Arizona BCBS Chairman of the Board Robert Bulla Result in Higher Copays for Chiropractic?
ACS research has uncovered a deep alliance between former Governor Janet Napolitano and Arizona BCBS Chairman of the Board Robert Bulla that may be at the root of the higher copays for chiropractic care.
In 2007, BCBS abruptly increased the copays and deductibles for chiropractic from PCP to specialist levels. ACS attorneys have determined this was a blatant violation of the chiropractic insurance equality law (CIEL), ARS 20-461. Nonetheless, in spite of repeated complaints, the Arizona Department of Insurance (ADOI), under the complete control of Governor Napolitano at the time, refused to act.
Now ACS has discovered the following close ties between the former Governor and long standing leader and now Chairman of the Board of BCBS, Robert Bulla:
1. The Governor appointed Mr. Bulla to the Arizona Board of Regents which oversees all state universities.
2. The Governor served with Mr. Bulla on the Board of Directors of TGen, the Translational Genomics Research Institute. TGen is a non-profit organization focused on developing earlier diagnostics and smarter treatments in a "relatively new field employing innovative advances arising from the Human Genome Project and applying them to the development of diagnostics, prognostics and therapies for cancer, neurological disorders, diabetes and other complex diseases." Click here list of members of TGen Board: http://www.tgen.org/about/index.cfm?pageid=33.
3. Robert Bulla was a member of the Board of Regents committee responsible for developing the Phoenix Medical School, a key priority for the Governor. Click here for an Arizona Republic article on the subject: http://www.azcentral.com/arizonarepublic/news/articles/2008/08/27/20080827biz-medschool0827.html.
4. This is an article from inside NAU with Board of Regents President Robert Bulla together with Governor Napolitano celebrating the opening of a conference center: http://www4.nau.edu/insidenau/bumps/2006/10_18_06/groundbreaking.htm.
Could Mr. Bulla have asked his close ally the Governor to tell her Department of Insurance to take no action when BCBS violated the chiropractic insurance equality law by raising the copays and deductibles in 2007? No one knows, but the fact is that under the reign of Governor Napolitano, the Arizona Department of Insurance stopped properly interpreting and enforcing the law, and one of the Governor's closest allies at the time was the virtual Godfather of BCBS of Arizona, Robert Bulla. Draw your own conclusions.
ACS has endorsed the ICA Best Practices and Treatment Frequency and Duration Recommendations, the Management of Whiplash Disorders Guidelines, and Chapter 8 of the Mercy Guidelines as practice guidelines for frequency and duration of chiropractic care. Click here for a comprehensive ACS position paper on this subject.
8. Necessary Step One to End Discrimination with Copays and Deductibles: File Complaints with the Arizona Department of Insurance
ACS has launched a plan to gain parity with MD and DO copayments and deductibles by filing complaints with the Arizona Department of Insurance (ADOI). The 1990 Chiropractic Insurance Equality Law ARS 20-461(A)17 and 20-461(B) prohibits discriminatory copays and deductibles. ADOI stopped enforcing the law in 2007. ACS recommends that policyholders file complaints whenever such discrimination is found. Click here for a sample complaint form to file with ADOI.
The next battlefront has been opened with the launching of ASH to manage the BCBS PPO beginning Jan. 1, 2011 and the CIGNA PPO April 1, 2011. ACS believes ASH will deny coverage for some reasonable and necessary chiropractic care in violation of Arizona state law, ultimately leading to litigation by ACS. The first step is filing complaints with the proper authorities. Here are instructions:
This deserves an entire page of its own. As of November, 2010, it has one. Click here to go to the ACS Chiropractic Insurance Equality Law Page. You will find links to every insurance equality law along with many newspaper and association articles about the laws and the political efforts associated with passing them over a twenty year period. Read the original 1990 Legislative Position Paper that provided supported for the laws by clicking here.
The Louisiana Department of Insurance in 2008 issued Directive 503 to implement its chiropractic insurance equality law which is modeled after Arizona's law, see below. ACS has asked the Arizona Department of Insurance to implement a similar order in Arizona since this would end current insurance discrimination with copayments, coinsurance and deductibles which are much higher for chiropractic than MD or DO care. Read the full Directive 503 here.
10. AAC Member Arlan Fuhr, D.C. and AAC Lobbyist Barry Aarons Helped UHC Pass a Virulently Anti-Chiropractic Law in 2004 Despite the Strenuous Objections of Both the AAC and ACS
This is a story that simply must be read in its entirety to be believed. In 2004, United HealthCare, wanting to have a tool to further crack down on chiropractic utilization, needed to pass a new law in order to single out chiropractors for utilization review. Current law prohibited focusing only on DCs and required equal attention to MDs, DOs and DCs with utilization review. Naturally, both ACS and the AAC opposed this attempt at reinstating discriminatory treatment for DCs. Suddenly at the 11th hour at the Capitol, the announcement was made that there was a new and third chiropractic association in Arizona that was the largest and in support of the UHC. The name? Activator Methods International, controllled by Dr. Fuhr. With that support, the bill then passed the Senate Health Committee. The AAC and ACS were still confident of defeating it in the full Senate until AAC lobbyist Barry Aarons went rogue and sided with UHC and Dr. Fuhr, telling key Senators moments before the vote that the AAC was neutral on the bill and no longer opposed. This caused two key no votes to turn to yes and thus the bill passed. The AAC never took action against either Dr. Fuhr or Mr. Aarons for this betrayal. Read the entire story with full documentation by clicking here. Mr. Aarons, having proven himself untrustworthy, remains the lobbyist for the AAC.
"Bad Faith: Fraud in the Insurance Industry" Insurance companies are always complaining about consumer fraud while they are committing loads of fraud on their own in-house. It's called "bad faith" and if you prove it then you may be able to collect punitive damages.
"There's fraud all right, committed by automobile insurance companies!" From The Scottsdale Tribune, by Dr. Immerman
Note to ACS Members: There is considerable additional valuable information available to you. Check under Breaking News for regular updates and contact ACS by phone or email for more information.