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July 2006, Vol. 16, No. 3
Table of Contents
Autism and Glutathione • CBP® Nonprofit has 24 publications in 12 months • CBP® Research Presented at the International Spine Conference in Norway • CBP® to File Lawsuit Against Quackwatch • CCE Weathers the Storm • Chiropractic Culture • Dr Don Harrison is ICA's Chiropractor of the Year • Dr Jim Gudgel to Co-Instruct With Neuromechanical Innovations • Dr Deed Harrison Speaks at Palmer West • Experimental or Medical Necessity • Fine Tune Patient Communication • From Screening to the Value of Proper Posture • ICA at the Table • ICA's Newly Elected Board Members • Instrument Adjusting's Mechanical Advantage • It's Don's Opinion • Letters to the Editor • My New Whiplash Text is Available • Patient Expectation and Retention • Principles, Ethics and Other Bygone Ideals • Problematic Decision Spectrum • Research Corner • Triano and CCGPP's Will Give You Six Visits
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Claims Being Cut?
Experimental or Medical Necessity?:
Use ERISA to get Paid
by James Sieffert, DC, CCSP, CSCS
1994 graduate from Northwestern College of Chiropractic. District Delegate to the Arizona Association of Chiropractic (AAC), Vice-Chair of the AAC’s Insurance & Health Services Committee
We are all aware of the policy bulletin Aetna put out in March on chiropractic treatment that they consider medically unnecessary or experimental and many have probably seen the updated version of their CBP® determination dated June 9, 2006. I applaud the Harrison’s for stepping up and hiring an attorney to fight Quackwatch and Aetna’s selective use of literature and opinion to say that the science of spinal correction is investigational and experimental.
In the meantime, there is another way to fight their (Aetna’s) tactics; on a claim, by claim basis. So that we can get paid in the mean time and perhaps donate to the cause. To do this, we as providers, have to be aware of something called ERISA and how to use this law to get what we and our patients deserve.
Most private sector health plans are covered by the Employment Retirement Income Security Act (ERISA). Among other things, ERISA provides protections for participants and beneficiaries in employee benefit plans (participant rights), including providing access to plan information. Also, those individuals who manage plans (and other fiduciaries) must meet certain standards of conduct under the fiduciary responsibilities specified in law. To be covered under ERISA, a plan has to be employer sponsored. A group health plan is an employee welfare benefit plan established, or maintained, by an employer or by an employee organization (such as a union), or both, that provides medical care for participants or their dependents directly or through insurance, reimbursement, or otherwise.
So what this means is that any patient who has health insurance through a private employer (non-governmental, church, or school board) whether self-insured or fully insured must follow federal law. These plans also have a responsibility to their enrollees to administer the benefits in fashion that insures the best interests of the beneficiary. They also have to have a plan document that tells the world what these benefits are and how claims will be handled, including any cost containment measures. This document is called the Summary Plan Description (SPD) and has to be provided with in thirty days when properly requested.
Below is from the Department of Labor Website regarding 29 CFR 2520.102-3- Contents of summary plan description:
For employee welfare benefit plans that are group health plans, as defined in section 733(a)(1) of the Act, the summary plan description shall include a description of any cost-sharing provisions, including premiums, deductibles, coinsurance, and co-payment amounts for which the participant or beneficiary will be responsible; any annual or lifetime caps or other limits on benefits under the plan; the extent to which preventive services are covered under the plan; whether, and under what circumstances, existing and new drugs are covered under the plan; whether, and under what circumstances, coverage is provided for medical tests, devices and procedures; provisions governing the use of network providers, the composition of the provider network, and whether, and under what circumstances, coverage is provided for out-of-network services; any conditions or limits on the selection of primary care providers or providers of specialty medical care; any conditions or limits applicable to obtaining emergency medical care; and any provisions requiring pre-authorizations or utilization review as a condition to obtaining a benefit or service under the plan. In the case of plans with provider networks, the listing of providers may be furnished as a separate document that accompanies the plan’s SPD, provided that the summary plan description contains a general description of the provider network and provided further that the SPD contains a statement that provider lists are furnished automatically, without charge, as a separate document. _http://www.dol.gov/ dol/allcfr/ebsa/Title_29/Part_2520/29CFR2520.102-3.htm_
So what we really have here is Aetna making an administrative decision based on their review of selected research and literature, that structural correction is not medically necessary. This does not mean a thing until the claim is filed and then denied. This is then known as an adverse claims determination and it can then be appealed under ERISA. The first thing the doctor’s staff needs to do is have a legal assignment of benefit that fits the definition in ERISA. Then when a claim is denied, request the SPD by certified mail, and review the actual coverage. If the service should have been covered, but has been denied as not medically necessary, then appeal the decision and attack their definition with the specifics of the service(s) at issue and demonstrating how and why the service at issue is not “experimental” and is medically necessary. If the first level appeal is denied, file a second level of appeal.
Under ERISA, the burden of proof once a claim has been denied is upon the provider to establish sufficient evidence for benefits. Also the requirements mandate total disclosure to inform claimant of reasons for the denial and access to plan document and right to appeal. Then ERISA requires the plan to perform responsibilities solely in the interest of the plan participants and their beneficiaries for the exclusive purpose of providing benefits to the participants and their beneficiaries and defraying administrative expenses.
ERISA can be a valuable tool to insure that our patients receive their entitled benefits. It should be our duty to learn how to take advantage of the protections offered and fight for our patients. So when Aetna denies your claim, make sure you follow the above steps and appeal their decision. I have supplied Don Harrison with copies of an assignment of benefit form and a letter to request the SPD, or contact me directly at drjames4@cox.net
Sample ERISA Assignment Letter
I assign the right to payment for all medical benefits directly to (names of all the doctors in the practice) in consideration for medical services and supplies provided pursuant to my health insurance plan.
In the event my health insurance plan refuses to pay for provided, medically necessary services, I also assign all my ERISA* rights to (names of all the doctors in the practice) for a full and fair review of any and all denied claims. This ERISA assignment is in consideration for the unpaid services provided and in consideration for the continued willingness of (names of all the doctors in the practice) to see patients, including myself, on an insurance assignment basis. I understand that if my treating doctor prevails in any such payment dispute, I may be liable for co-payment for the contested services.
I give consent to release medical information to (names of all the doctors in the practice). I give consent to (names of all the doctors in the practice) to release medical information to other healthcare providers for the purpose of treatment, when necessary for my care. I give consent to (names of all the doctors in the practice) to send medical information, as necessary, to my insurance plan.
*ERISA is an acronym for the Employee Retirement Income Security Act. The Employee Retirement Income Security Act includes federal laws requiring insurance companies to process submitted insurance claims and appealed (denied) insurance claims according to ERISA regulations. The failure to process submitted insurance claims and appealed (denied) insurance claims according to ERISA regulations may result in fines charged to the insurance company in amounts up to $110 a day for each infraction.
_________________________________
Patient’s printed name
_________________________________
Patient’s signature
Date______________________________
Letter to Request for a Copy of the Summary Plan Description,
Claim Appeal Procedure, and Explanation of Chiropractic Benefits
[Date]
[To:] Plan Fiduciary
[Re:] Patient name/address/telephone number/date of birth
Social Security (or health plan identification) and Group Policy numbers
Sent via US Postal Service - Certified Mail
Dear Sir:
This letter is to request a complete copy of the following for the above noted patient.
_ Summary Plan Description (SPD)
_ Plan Claim Appeal Procedure
_ Full Explanation of Chiropractic Benefits
Enclosed please find a signed copy of the patient Authorization Form authorizing me to act as the patient’s representative.
This request follows U.S. Department of Labor guidelines that indicate:
“A plan’s claims procedures may not preclude an authorized representative (including a health care provider) from acting on behalf of a Claimant and further provides that a plan may establish reasonable procedures for verifying that an individual has been authorized to act on behalf of a Claimant.”
Please note, an enrollee/beneficiary may file suit against a Plan Administrator who fails to comply with the enrollee’s/beneficiary’s request for a copy of the latest SPD. Section 502(a)(1)(A) of ERISA indicates the Plan Administrator has thirty (30) days to provide the SPD to the enrollee/beneficiary. The Plan Administrator may be held liable for up to $110.00 per day for each day he/she fails to provide the SPD to the enrollee/beneficiary.
Should you have any questions, feel free to contact me. Thank you for your prompt response to this request.
Sincerely,
[treating provider]
[treating provider address, telephone number, and license number]
cc: [insert patient name and address]
Attachment
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