Are Insurers Aware of Their Legal Obligations to DCs?
Written by Editor   
Tuesday, April 16, 2019 08:00 PM

Excepted and expanded from Are Insurers Aware of Their Legal Obligations to DCs? by James Lehmann, DC, MBA, FACO

What are the changing ethical and legal business behavior expected from health insurance companies based upon federal law.  Over the decades that have been many changes regarding reimbursement by third-party payers for chiropractic services. First, there were reasonable and necessary reimbursements from insurance companies. Then came managed care. The managed care companies often claimed to practice medicine, and frequently generated severe reductions in reimbursement and caused increased administrative costs for providers. Now, we struggle with documentation issues, restrictive guidelines and shrinking third-party reimbursements.

What are the legal obligations of insurers?  Of primary consideration should be Section 2706of the Affordable Care Act (ACA), “Nondiscrimination in Health Care.” It requires that insurers include and reimburse licensed health care providers in health insurance plans stating that: 

“A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certifcation under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.”

Chiropractic physicians must take the bull by the horn and question whether insurance companies are aware of their legal obligations to provide non-discriminatory reimbursements.  According to Section 2706, insurance companies are required notto discriminate against chiropractors, and must reimburse chiropractic physicians at the same rates for the same services as provided by physical therapists, medical doctors, osteopathic doctors, APRNs and PAs.

The insurance companies are maximizing their profit and returns on investments to stockholders by reducing costs while increasing premiums. Unfortunately, these cost reductions are achieved by reducing paymentfor services rendered through a process referred to as economic credentialing. 

The American Medical Association offers the following definition of economic credentialing:

Economic credentialing is a term of disapproval used by the American Medical Association (AMA). The association defines the term as "the use of economic criteria unrelated to quality of care or professional competence in determining a physician's qualifications for initial or continuing hospital medical staff membership or privileges.”

Are we doing anything to make the insurance companies aware of their legal obligations to chiropractic clinicians for services rendered? Is political activity aimed specifically at educating the insurance companies of their legal obligation to properly reimburse DCs for services rendered to patients in need of care.    

Perhaps some of the stronger chiropractic state associations will seek legal advice and pursue educating insurance companies of their legal obligations to reimburse chiropractors without discrimination. Perhaps a legal suit will need to be filed in order to force the insurance companies to follow this federal law.

Either way, it is up to us to make sure that the insurers are aware of their legal obligations.