THE ACS FOUR POINT PLAN TO DEAL WITH ASH
1. ASH allows an average of 6.5 chiropractic visits per patient nationwide according to statements made to Arizona chiropractors.
2. ASH intends to allow one additional CPT code for a physical medicine procedure in addition to a spinal manipulation code per visit.
3. BCBS has a long history of allowing an average of at least 25 visits per patient and three additional CPT codes for physical medicine procedures per visit.
4. ASH/BCBS will require preauthorization for all chiropractic visits after the fifth visit for in- and out-of-network claims beginning Jan. 1, 2011.
5. Arizona law, specifically ARS 20-461(A)17 and 20-461(B), requires that BCBS cover all "reasonable and necessary" chiropractic care. The law also requires that all "cost containment measures" such as preauthorization be applied equally to MDs, DOs and DCs.
6. ASH spends close to 50% of premium dollars on administration and profit.
ALLEGED VIOLATIONS OF LAW BY BCBS/ASH
1. Failure to cover all reasonable and necessary chiropractic care. Literally no one except ASH believes that 6.5 visits per patient constitutes all reasonable and necessary chiropractic care. Standing against ASH is every professional chiropractic guideline ever published including the Mercy Guidelines, every state and national association, every chiropractic college, and almost every single licensed chiropractor in the US. Courts are guided by what is called "the general consensus of the relevant scientific community." The general consensus of the chiropractic community in Arizona is that about 25 visits is reasonable and necessary for the average patient, and that 6.5 visits is gross under treatment.
2. Failure by BCBS to spend at least 85% of premium dollars on patient care, and spend no more than 15% on administration and profit. ACS has the financial reports for ASH which document that approximately 50% is spent on administration and profit. This will be illegal under federal law beginning Jan. 1, 2011.
3. Failure to apply cost containment measures, in this case preauthorization, equally to MDs, DOs and DCs. BCBS is not going to require MDs and DOs to get preauthorization to see their patients after the fifth visit. This is illegal discrimination under the law.
THE ACS FOUR POINT PLAN TO DEAL WITH ASH
1. File a lawsuit against the Arizona Department of Insurance (ADOI) in early 2011 if ADOI does not force BCBS to cover all reasonable and necessary chiropractic care and if ADOI does not force BCBS to apply cost containment measures (preauthorization) equally to MDs, DOs and DCs. If ASH limits the average patient to 6.5 visits and 2 CPT codes per visit, and if ASH requires preauthorization only for DC patients but not MD and DO patients after the fifth visit, ACS will support litigation against ADOI.
a. This will simply require having a few patients who are denied care after 6-7 visits but who clearly need more care file complaints with ADOI.
2. File a class action Federal Court ERISA lawsuit against BCBS for narrowing the chiropractic benefit without specifically changing the underlying plan documents and insurance policies to reflect the changes. BCBS will have reduced the average number of visits per patient from approximately 25 to 6.5, and the number of CPT codes per visit from 4 to 2. This cannot be done under ERISA without changing the language of the official ERISA Plan Document. This lawsuit is so strong that our ERISA attorney is willing to file it on a contingency fee basis.
3. File bad faith lawsuits on behalf of individual BCBS policyholders. Certify the individual policyholders as a class and turn this into a class action lawsuit on behalf of all BCBS individual policyholders. ERISA pre-empts bad faith and so patients who receive their policies from employers cannot sue for bad faith and punitive damages. Individual policyholders, however, preserve their rights to file bad faith lawsuits. The ACS bad faith insurance lawyer has advised that if BCBS narrows the chiropractic benefit in the middle of a contract year, this may constitute bad faith. A lawsuit would ask for punitive damages which means sufficient money to teach BCBS a lesson about cheating people. The settlement could be hundreds of millions of dollars in order to get the attention of a large company like BCBS. These lawsuits are also so strong that they would be contingency fee based.
4. Ask the appropriate governmental agency to take action to enforce the new law requiring BCBS to spend at least 85% of premium dollars on patient care. We have the reports that ASH spends about 50% on patient care and 50% on administration and profit. Considering the fact that ASH babysits every chiropractic patient under their purview, it is no surprise that their administrative cost are so high. After Jan. 1, 2011, however, such exorbitant and wasteful spending will be illegal.
The ACS Four Point Plan to deal with ASH will result in BCBS once again covering the full reasonable and necessary amount of chiropractic care, not just 6.5 visits per patient and 2 CPT codes per visit. ASH will either have to change its practices, or BCBS will have to get rid of ASH. This should be accomplished in 2011.
Success is contingent on sufficient doctors contributing funds to support the lawsuit against ADOI over ASH. ACS has fully funded the lawsuit over the illegal copayments. ACS will need $500 per doctor or as close to that amount as possible in order to sue over ASH. Send donations to ACS, 3515 E. Carol Ave., Phoenix, AZ 85028. If you are not a member, join in order to help support the monthly legal fees and costs. You can find a membership application and regular updates about BCBS, ASH and many other important chiropractic issues at our totally revamped website at www.AZChiropractors.org. You must visit the ACS webpage to see all the exciting new changes and information!