BY SIGMUND MILLER
COMMENTARY
The recent revelation that Horizon Blue Cross Blue Shield of New Jersey (Horizon) CEO William Marino's compensation package last year was nearly $9 million has come as no surprise to the tens of thousands of doctors and patients throughout New Jersey who have been cheated by the healthcare giant for many years; especially to the Association of New Jersey Chiropractors (ANJC), which represents over 1,600 chiropractors statewide.As the outcry continues from the general public, legislators, and medical practitioners across the state for legislative hearings regarding Horizon's outlandish executive compensation packages, the ANJC, whose members have experienced first-hand the intransigence and audacity exhibited by Horizon, continues to pursue several strategies to rectify various injustices visited upon chiropractors in New Jersey and their patients by Horizon.
For example, on May 25, the United States District Court for the Northern District of Illinois upheld claims filed under the Employee Retirement Income Security Act of 1974 (ERISA) against 22 leading Blue Cross Blue Shield insurers across the country, including Horizon. The action was filed by a number of individual healthcare providers on behalf of a putative nationwide class of healthcare providers, and multiple state chiropractic associations on behalf of their members, including the ANJC, the Pennsylvania Chiropractic Association, the New York Chiropractic Council, the Florida Chiropractic Association, and the California Chiropractic Association.
The lawsuit challenges the BCBS defendants' abusive practices in using post-payment audits, improper repayment demands, and automatic recoupments, to pressure providers to repay substantial sums that have previously properly been paid on behalf of BCBS subscribers. In denying a series of motions to dismiss the case, the court validated the Plaintiffs' primary legal claim that even retroactive claim denials, including those made as a result of a post-payment audit, require proper appeal rights and other procedural protections under ERISA. The Court also upheld the rights of the state chiropractic associations, including ANJC, to pursue significant policy changes in these auditing and recoupment practices on behalf of their members.
Through the lawsuit, the ANJC hopes to level the playing field for chiropractors facing repayment demands from Horizon by requiring Horizon to fulfill its existing obligations under the law. "We are not challenging Horizon's right to audit claims to ensure payments are made appropriately," said John W. Leardi, Esq., of Buttaci & Leardi, LLC, Special Counsel to ANJC, and co-lead counsel in Pennsylvania Chiropractic Association et al. vs. Blue Cross Blue Shield Association et al., Case No. 1:09-cv-05619. "But too many chiropractors in this state have been unfairly subjected to inflated or otherwise illegitimate overpayment demands from Horizon and been forced to settle because of an inherently unfair process. What we want is a process that requires transparency and fairness; a process where a doctor is given a meaningful opportunity to understand and object to an overpayment demand before facing automatic recoupments from current claims."
The ANJC also continues to fight for fair reimbursement to its members by Horizon on the "front end." For years Horizon, unlike virtually every other private insurance carrier doing business in New Jersey, refused to pay chiropractors separately for patient exams and physical therapy modalities. Instead, Horizon "bundled" reimbursement for these services into payments for chiropractic adjustments. Last October, however, the Department of Banking and Insurance (DOBI) held that Horizon's chiropractic reimbursement policies violated the New Jersey Unfair Claims Settlement Practices Act and ordered Horizon to cease and desist from "bundling" payment for patient exams and physical therapy modalities into the reimbursement it pays for chiropractic adjustments. Nevertheless, it was not until April 15, 2010, that Horizon finally began processing and paying these claims separately in compliance the DOBI's order.
Certainly the DOBI order was a tremendous victory for chiropractors in New Jersey and, more importantly, their patients. And to Horizon's credit, they appear to have stopped bundling chiropractic services on all claims, including those submitted to self-funded plans, which fell outside of the DOBI order. But they have not addressed the thousands, if not millions, of chiropractic claims that were improperly denied in violation of the Unfair Claims Settlement Practices Act prior to October 7, 2009. And frankly we owe it to our members and their patients to explore all possible avenues of potentially recovering these amounts, which we believe are substantial.
The bottom line is that chiropractors and their patients in New Jersey have been subjected to unfair treatment by Horizon for years. So the recent news that last year, when health insurance premiums increased an average of 25% and the economy nearly ground to a standstill, top Horizon executives collected over $24 million in bonuses, came as no surprise to the ANJC, its members, and chiropractic patients throughout the state.
Dr. Sigmund Miller is Executive Director of the Association of New Jersey Chiropractors.