April 25, 2011 — The American Chiropractic Association’s (ACA) Board of Governors has voted to join an existing class action lawsuit against UnitedHealthcare (United) initiated by the Ohio State Chiropractic Association, the Congress of Chiropractic State Associations and others.
ACA’s involvement will expand the litigation to include problems with United’s claims review, tiering and payment policies.
Filed on Jan. 24, 2011, the litigation represents a nationwide class of healthcare providers who were subjected to United’s improper recoupment of payments for services provided to United subscribers.
In instances where providers could not offer immediate repayment, United forcibly recouped the payments by withholding reimbursements from subsequent unrelated United claims — an alleged violation of the Employee Retirement Income Security Act of 1974 (ERISA), the federal law governing private employee benefit plans.
On April 22, 2011, ACA amended the original complaint alleging that the use of post-payment audits and recoupments is only part of the scheme undertaken by United to enhance profits through denial of benefits otherwise due and payable under the insurer’s plans. In particular, the complaint alleges United, through its chiropractic network, OptumHealth, adopted a series of internal policies and procedures intended to improperly deny benefits.
The amended complaint outlines additional allegations, including:
- Appeal rights have not been consistently afforded to patients when the care authorized differs from the doctor’s care plan, in violation of ERISA.
- Optum, in a deliberate effort to avoid its obligations under ERISA, refuses to allow providers to request a particular number of visits or procedures, or to submit clinical information necessary for utilization review.
- Providers are subjected to threatening communications in an effort to pressure them to reduce utilization rates.
- Optum relies on statistically invalid data to determine average utilization rates. It further manipulates data and pressures providers to reduce care, thereby reducing what is reported as the “community standard” for proper levels of care.
- Even though doctors only provide the services pre-authorized by Optum, the network continues to declare that the averages derived from those authorizations are inappropriate and pressures providers to reduce care.
- ACA’s amended complaint requests the federal court to enjoin United from continuing to apply the Optum policies that are used to improperly reduce coverage for chiropractic services, and order United to disgorge the profits it has earned by denying such coverage, through its actions taken in violation of ERISA, plus interest.
“United’s attempts to intimidate and coerce patients and providers can no longer be tolerated. They must be challenged with a unified effort by the chiropractic profession,” said ACA President Rick McMichael, DC. “Patients’ right to receive medically necessary care must be protected and insurers must be held accountable to pay for care patients have paid for through their insurance premiums. Patients will only get proper care if their doctors are free to act in the patient’s best interest, without undue restriction from managed care organizations.”
ACA urges providers who believe they and/or their patients have been affected by United or Optum’s unfair practices to visit the Chiropractic Networks Action Center (CNAC) where they will find instructions and forms that can be used to submit a complaint to the Association. The CNAC may be accessed by going to: http://www.acatoday.org/CNAC.
Source: American Chiropractic Association, www.acatoday.org
