ACA calls for crackdown on fraud, unsafe exams
On the heels of a "Dateline NBC" expose on State Farm Insurance Co.’s alleged unfair denial of medical claims, the American Chiroprac-tic Association (ACA) is calling on every state insurance commissioner to investigate many "out-of-control" medical review programs by "incompetent" claims reviewers that have placed patients at risk.
"Dateline NBC’ made the entire country aware of what we have always known," writes ACA president James Mertz, DC, DACBR, in a letter to every state commissioner of insurance. "Many insurers and their selected vendors who perform medical review are not accountable for their cost-cutting guidelines and, in many cases, are incompetent. Thousands of complaints are received from our members that cite these injustices, which we believe are not consistent with fair claims practices."
In his letter, Mertz expresses the ACA’s support for the National Association of Insurance Commissioners’ (NAIC) investigation into unfair claims practices, and extends ACA’s assistance to state agencies to help develop local solutions. In a recent series called "The Paper Chase," "Dateline NBC" correspondent John Larson uncovered disturbing claims review practices by State Farm and other major insurance companies. The broadcast prompted not only an investigation into those practices by NAIC, but also concern among members of the powerful House and Senate Commerce Committees, who vowed to fully examine the problem.
According to the ACA, unfair medical review practices hit the chiropractic profession especially hard. The ACA estimates that doctors of chiropractic spend a significant amount of their overhead expenses communicating with insurers on medical review issues.
The letter, which was copied to state governors, the NAIC, and the Insurance Regulatory Examining Society, included a list of more than a dozen complaints ACA commonly receives from its members regarding unfair claims practices.
Here are some of the complaints received from ACA members regarding unfair claim practices:
• Clinically untrained individuals performing reviews are not trained in patient treatment protocol, and are ill-equipped to discuss such matters with treating providers.
• Registered nurses create software edits and establish medical review policy without the benefit of input from the specialties that are most affected by such policy.
• Medical directors often ignore input from specialty groups and implement medical review policy that is consistent with their own thinking. It does not reflect current practices of other disciplines.
• Insurers and vendors employ chiropractic consultants, but don’t necessarily use their input in decision making or medical review policy development.
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