American Chiropractic Association Files Lawsuit
Against ACN in Federal Court

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

FROM:   American Chiropractic Association ~ June 13, 2006

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The American Chiropractic Association (ACA) today asked the U.S. District Court in Miami to allow ACA to join as a plaintiff in the pending nationwide class action lawsuit Solomon v. Anthem, et al., and further asked that ACN Group, Inc. and United Healthcare Services, Inc. be named as additional defendants in the case. The ACA alleges that ACN participated with other managed care companies in the case in a conspiracy to illegally and systematically underpay providers by denying reimbursement for medically necessary treatment.

ACA, along with other national and state health care associations, individual doctors of chiropractic and other health care providers, challenge the utilization review and payment practices of some of the nation’s largest managed care companies, including Health Net, Humana, PacifiCare Health Systems, Aetna, United Healthcare, Wellpoint Health Networks and Prudential. The case alleges that these companies, including ACN, violated the Racketeer Influenced and Corrupt Organizations (RICO) Act by systematically and illegally denying, delaying, and diminishing payments owed to chiropractors and other health care providers.

Joining the ACA in its efforts against managed care companies, particularly ACN, is the Connecticut Chiropractic Association, who is also seeking to be named as a plaintiff in the litigation. The Florida Chiropractic Association is also a plaintiff.

“There is simply no greater priority for ACA than to oppose what we view as the abusive tactics of ACN and other managed care organizations who systematically deny needed chiropractic care to our patients,” said ACA President Richard G. Brassard, DC.   “Doctors from across the country have provided us with reports of intimidation and coercion conducted under the guise of utilization control. This can no longer be tolerated by a profession dedicated to quality patient care.   The ACA intends to expend every effort and seek every possible legal remedy to put a halt to these harmful practices.”

The suit calls into question the use of financially expedient cost and actuarial criteria rather than appropriate bases of medically necessary treatment for utilization review, and alleges that these criteria are purposely imposed on providers with the knowledge that they cannot be met. Through this legal action, ACA will seek damages against ACN and the other defendants in the case on a class-wide basis. It will also seek to obtain injunctive relief to bring an end to what it views as the abusive practices and procedures of ACN.

“Our case involves protection of the doctor-patient relationship as to whether care will be provided on the basis of medical necessity, or based on what we believe are contrived policies and statistics skewed to maximize profits for managed care organizations such as ACN,” said ACA Chairman Lewis Bazakos, DC.

Specifically, the complaint states the defendants, including ACN:

• Systematically refused to compensate health care providers for covered services;
  

• Processed health care providers’ claims using either automated programs which manipulate standard coding processes or use unqualified personnel to determine whether or not the service provided was medically necessary and covered;
  

• Downcoded and bundled legitimate claims to less costly procedures;
  

• Arbitrarily refused or reduced payment for certain categories of treatment;
  

• Systematically failed to recognize valid assignments of benefits; and,
  

• Delayed payments to health care providers by requesting additional documentation, even when such documents should not be required.

The ACA’s overall campaign to correct the harmful practices of some managed care networks is an outgrowth of a resolution passed by the ACA House of Delegates in March 2002 formally outlining ACA’s opposition to the improper practices of chiropractic networks.

“Doctors are being forced out of their practices daily by the abusive tactics of ACN and other managed care organizations.   The ACA has listened to these doctors and other doctors practicing under the threat of unwarranted terminations,” Dr. Brassard said.   “Like the generations of chiropractors before us, the ACA will not back away from its responsibility to protect the profession and the patients we serve.   We ask the entire profession to unite with us in this effort, as the outcome will profoundly affect the way chiropractic care is provided now and in the future.”

Actions at the State Level

In addition to the filing of this national class action, ACA—in cooperation with several state chiropractic associations—is actively engaged with a number of state attorneys general, offices of insurance and boards of licensure, and the Federation of Chiropractic Licensing Boards (FCLB) regarding the tactics undertaken by ACN.

To help augment the legal efforts underway by ACA, individual doctors of chiropractic and chiropractic state associations are being asked to take action by filing complaints with state regulatory agencies. Furthermore, doctors are encouraged to use ACA’s ERISA pre-service template letters, found at ACAtoday.org/networks, to notify a patient’s employer that the benefit they purchased for the employee is not accessible when medically necessary treatment is denied.

To view copies of pleadings filed by ACA in the U.S. District Court in Miami, or for more information on ACA's managed care initiatives, visit ACA's Chiropractic Networks Action Center.

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Since 6-13-2006