The meeting between the Arizona Department of Insurance and the chiropractic community on 04/18/13 was entirely nonproductive as ADOI refused to agree with any of the concerns expressed by ACS. Below are each of ACS' complaints with ADOI's responses.
Complaint One: Failure to equally apply cost containment measures, in this case precertification, to MDs, DOs and DCs.
ADOI initially stated that precertification is a contractual matter between the doctor and insurer that cannot be regulated by ADOI. ACS responded by saying that precertification is being applied to non-contracted providers and so is an issue of insurance contracts, not provider contracts. ADOI never directly addressed this issue and the meeting ended with no commitment to deal with the fact that precertification is only being applied to DCs and not to MDs and DOs which is a violation of the law.
Complaint Two: Failure to pay charges for all reasonable and necessary chiropractic treatment for covered conditions.
ADOI stated that the only recourse when any insurer does not cover all medically necessary care is for doctors and patients to use the Arizona Health Care Appeals system. This is a three level appeals system with the third level being a review by an external independent reviewer chosen by ADOI. Very few doctors are using this system at the present time. Everyone should begin using this process immediately. Go to http://www.id.state.az.us/publications/Guide_to_Healthcare_Appeals_09.pdf for full information about how to do so. ADOI has no intention to deal with the overall ASHN protocol aimed at forcing doctors to under treat patients.
Complaint Three: Charging a copayment, coinsurance and deductible that is higher for chiropractors than it is for primary care physicians
ADOI stated that the informal advisory letter from the Attorney General stated that it is legal for insurers to charge higher copays, coinsurance and deductibles for chiropractors than for PCPs. ACS noted that the letter required insurers to establish criteria for designating chiropractors as specialists that do not discriminate against the usual and customary treatment procedures of chiropractors. ADOI stated that was not really a requirement when you read the entire AG letter and so ADOI will not require insurers to develop such criteria.
Complaint Four: Marketing and selling chiropractic coverage, but not actually delivering it, i.e., an "illusory benefit"
ADOI responded by saying this is a large "global and political issue" that their agency cannot address, period and conclusion. Insurers will still be able to say they sell chiropractic coverage but only pay $4 out of a total $44 visit, something that ACS considers consumer fraud.
Complaint Five: Applying a limitation or condition upon payment to or upon services, diagnosis or treatment by DCs but not by MDs or DOs
ADOI stated that insurers are allowed to place limits on the treatments given by chiropractors while not placing limits on the different treatments given by MDs and DOs. This neuters the language that prohibits discrimination against "the usual and customary treatment procedures of an MD, DO or DC." ADOI seems unable to understand the meaning of this clause and so is unable and unwilling to enforce it.
Complaint Six: Failing to Pay Charges for Reasonable and Necessary Chiropractic Services
ADOI is totally unwilling to consider the amount paid for any service rendered by chiropractors. There is no minimum amount that would trigger action by ADOI.
Our hopes now ride on the class action lawsuits we are planning on filing directly against the insurance companies in Arizona. We are working with three law firms across the country. One is on the verge of filing a lawsuit in the very near future, and the other two are in the planning phases. In the meantime, ACS will be providing you with detailed information regarding how to file appeals using the Health Care Appeals system, Grievance Letters using a separate system, timely payment of claims complaints, and more. Stay tuned for comprehensive directions. There is much that can be accomplished using existing laws.
ADOI Acting Director Marks has not yet been confirmed as Director by the Arizona State Senate. Her nomination was approved by a Senate committee, but a vote by the full Senate has not been scheduled. There are legislators who were waiting to see the outcome of the meeting with the chiropractic community before scheduling the vote by the full Senate. We do not know if a vote will be scheduled after yesterday's very disappointing and completely nonproductive meeting. The only positive thing we can report from the meeting is that it was very cordial and polite and for that we are quite grateful. However, nothing was accomplished to reverse the downward spiral of insurance coverage for chiropractic in Arizona. The battle rages on.
