SAMPLE ATTORNEY GENERAL COMPLAINTS TO BE FILED NOW AGAINST ASH
It is essential that you file Consumer Fraud and Misrepresentation complaints with the Attorney General's office against BCBS and ASH as soon as possible and frequently when appropriate. Here is the webpage with a link to an online complaint form: http://www.azag.gov/AllComplaints.html.
On the form, you are asked: "Please explain the entire circumstances surrounding your complaint below. Please fully describe any oral or written misrepresentations made to you." Here are sample answers you should provide:
STOP AND READ: You must modify these forms before just cutting and pasting them to the AG's webpage. Where it says "FILL IN THE NAME HERE" AND "FILL IN THE NUMBER OF VISITS HERE" AND "XXXXXXX", YOU MUST SUBSTITUTE THE NAME AND NUMBERS FOR THESE WORDS. THIS IS A KEY POINT! Here are the sample complaints:
- "All health insurance contracts issued by Blue Cross Blue Shield of Arizona (BCBSAZ) state coverage will be provided for all medically necessary chiropractic care in accord with the requirements of ARS 20-461(A) 17 and ARS 20-461(B). In the case of my patient, (FILL IN THE NAME HERE), the vendor hired by BCBSAZ to manage chiropractic claims, American Specialty Health (ASH), determined that all of the chiropractic care after the first (FILL IN THE NUMBER OF VISITS HERE) was not medically necessary.
My clinical determination that these visits were medically necessary was based on all professional guidelines and standards widely accepted by the chiropractic profession, see http://www.azchiropractors.org/ACSPracticeGuidelinesPage.htm for documentation. The ASH allowance for amount of care is so grossly inadequate and inconsistent with generally accepted standards for chiropractic that it clearly constitutes consumer fraud. It is completely contrary to the BCBSAZ contracts which state there will be coverage for all medically necessary chiropractic care. BCBSAZ has misrepresented the facts in its insurance policies when it states there is coverage for all medically necessary chiropractic care at the current time. There most certainly is not. This is consumer fraud.
ASH routinely denies some medically necessary chiropractic care as they did with my patient who the subject of my complaint. BCBSAZ must not be allowed to advertise and contract to provide all medically necessary chiropractic care and then use its vendor ASH to routinely deny substantial amounts of necessary care based on false standards concocted in-house and not accepted by anyone in chiropractic other than the few doctors working at ASH. This is a sophisticated consumer fraud operation designed to deny insurance policyholders some of the actual benefits for which they have paid and which the law cited above requires insurers to provide. Please investigate and resolve this consumer fraud as soon as possible."
- "All health insurance contracts issued by Blue Cross Blue Shield of Arizona (BCBSAZ) state coverage will be provided for all medically necessary chiropractic care in accord with the requirements of ARS 20-461(A) 17 and ARS 20-461(B). In the case of my patient, (FILL IN THE NAME HERE), the vendor hired by BCBSAZ to manage chiropractic claims, American Specialty Health (ASH), determined that all of the chiropractic care we have clinically determined is needed per visit is not medically necessary.
I have determined that four separate treatment procedures per visit are medically necessary. This is based on my examination, diagnosis and all professional guidelines and standards widely accepted by the chiropractic profession, see http://www.azchiropractors.org/ACSPracticeGuidelinesPage.htm for documentation. ASH only allows two procedures per visit. This restricted and limited amount of care for my patient is so grossly inadequate and inconsistent with generally accepted standards for chiropractic that it clearly constitutes misrepresentations and consumer fraud. It is completely contrary to the BCBSAZ contracts which state there will be coverage for all medically necessary chiropractic care. BCBSAZ is now covering 50% of my patient's medically necessary chiropractic care, not the 100% required by contract and law.
ASH routinely refuses to authorize two of the four prescribed procedures per visit as they did with my patient who is the subject of my complaint. BCBSAZ must not be allowed to advertise and contract to provide all medically necessary chiropractic care and then use a vendor named ASH to routinely deny a full 50% of the necessary care per visit based on false standards concocted in-house and not accepted by anyone in chiropractic other than the few doctors working at ASH. This is a sophisticated consumer fraud scheme designed to deny insurance policyholders a full 50% of the benefits for which they have paid and which the law requires insurers to provide. Please investigate and resolve this consumer fraud as soon as possible."
- "In order to for a policyholder to collect insurance benefits, the insurer must make personnel available telephonically within a reasonable period of time. On the date of XXXXXXX, I called American Specialty Health (ASH), the vendor chosen by BCBSAZ to handle chiropractic claims, and was placed on hold for XXXXXXX minutes before I had to terminate the call to move onto other business. The industry standard is no more than a 15 minute wait time and ASH's far longer wait time of XXXXXXX minutes is simply another way to deny contracted insurance benefits to policyholders. Please investigate and resolve this additional form of systemic consumer fraud."
These are just samples. Only use them if the facts apply to your office. If and when you run into other problems with ASH, modify these letters and write your own unique complaint. The key point is that you must send in an online complaint each and every time ASH misbehaves. We want hundreds if not thousands of consumer fraud complaints filed with the AG's office immediately. This is an essential part of our overall strategy.
