Ah, what is an ethical doctor to do? Last January, we received a letter telling us that we can only continue our participation in Cigna Open Access Plus and the PPO if we become credentialed with a company called American Specialty Health Networks. We did not accept the Cigna HMO since ASHN took over their network around 1999, when their other vendor went out of business because or the perceived reputation that ASHN had. I was not thrilled, since two years previous, I had helped save Cigna's previous HMO network who was also hurting chiropractors financially by underfunding a capitated plan and not communicating with Cigna that a problem existed. Cigna historically likes to use vendors instead of administrating certain professions such as chiropractors directly. We did credential with ASHN for a short time about 11 years ago and quickly left when we saw what was required of doctors in the network (reams of paperwork and faxes). Over the last 10 years, Cigna had grandfathered us into their PPO without having to deal with ASHN which gave us the freedom to do what we thought was best for our patients. A few years ago,A Cigna representative convinced us to join their Open Access Plus networks as well which we joined under the condition that we did not have do deal with ASHN. Cigna's management under Open Access Plus and PPO plans was transparent and they allowed us to do what was necessary. We had many patients in the expanding Open Access Plus network and it worked well for the past few years.
Fast forward to 2010, we felt compelled to credential with ASHN, despite their reputation among my colleagues as being a paper and payment nightmare because Cigna now said that we can only continue our participation by joining the network. Some of my colleagues were exiting the network as I was credentialing however, I was willing to give it 6 months to try the network out.
They send us a large credentialing packet on CD with all the plans, their fee schedules and most of what I needed to decide if this could work, since we handle many managed care plans. The Cigna HMO fee schedule was quite low, if not below our cost of doing business however, the local rep assured us they would be fair but conservative. We were told that they would put us in a tier allowing us 5 office visits before any paperwork was necessary on their HMO patients. We were also told that Open access plus and the PPO, who had similar fee schedules in their packets to the ones under Cigna directly did not require any paperwork. In other words, things would not change other than who we bill through.
We officially joined as of 4/1/10 and had our first two HMO patients, and had programmed our computers to handle the fee schedules for their other plans as well under Cigna. There was little training for their paperwork and the first two were problematic because they gave us far fewer visits than we asked for. I finally spoke with the doctor in charge of the NJ reviews who stated that Cigna under ASHN's management is an acute only plan and does not cover any rehab. He agreed to cover the 12 visits one patient had and the 8 visits the other needed and explained that the paperwork should have been filled out for the 1st visit, even though we do not need to submit it until the 5th. We were told to fill it out after the 5th. After that conversation, all our Cigna HMO patients thereafter were required to sign an agreement saying they understand they can rehab, however, at their own cost.
We thought everything was fine until we did not receive any Cigna payments for their other plans for over two months. When we received them, the payments were far less than we expected and then when we inquired about the Open Access Plus claims being paid improperly, we were given a different fee schedule than the one in the packet, that was markedly lower in many ways. We also then found out that all their plans required certification, including non gaited plans (PPO and Open Access Plus) and we had been lied to or deliberately misinformed. This meant we now had to scramble to do precertification paperwork on a bunch of people, some who could not fill out questionaires since they were no longer under care. We submitted these care plans and they either denied increased treatment past 5 visits or gave us visits but reduced time frames that we billed within. We called and their staff said to file for extensions which were of course denied. I then requested that I speak with their medical reviewer who stated that during our last conversation in June, he believed that he was clear on the acute thing. I said I was and then he could not believe we were misinformed by their staff, offering little other than an apology and suggested more paperwork in the form of a continuing care paper form, to add to the other stuff we were already sending in, to get paid at less than were were paid before.
The final straw for us was a bounced check from ASHN, on services that we waited for payment for over two months.
As our patients know, I do my best for them. Back injuries, neck injuries, shoulder injuries and other problem we see patients for all require rehab to get the problem corrected. I believe it is wrong to tell someone that we will serve them half way for their co pay and then the rest is their problem. It just isn't right. It also is not right for an employer who to buys benefits that are advertised for up to 60 per year to have their employees find out it is limited it to 6 or 7. Bait and switch plans are not ethical.
Last night, after less than four months, I mailed and faxed in my resignation to ASHN. They are indeed a nightmare. They call themselves conservative. I call them intrusive and overbearing. I can now understand how they single handedly destroyed the economic viability for chiropractors who work in California, where they yield alot of influence.
For those of you who wish to continue under our care, we will continue to participate until the 60 days or so that are required have expired. After that, we will be out of network as a provider for Cigna. It is better that way and I believe our patients will find their out of network benefits are more beneficial without the interference of ASHN. For anyone else reading my blog, including other doctors in my profession, I am not suggesting any course of action, however, if your experience is similar to mine, you will have some thinking to do.
Was leaving the right thing to do? I believe it was. Working harder for less reimbursement and cheating patients out of their benefits was not what I signed up for. In my office, it is quality or nothing. In the case of the Cigna plans, I would rather be out of network where quality can exist. What do you think? I value your input.