In the latest example of chiropractic fighting back against insurance giants, the Association of New Jersey Chiropractors (ANJC) has filed a class-action lawsuit against Aetna, alleging that the insurer's postpayment audit procedures violate the Employee Retirement Income Security Act of 1974 (ERISA) and the Racketeer Influenced and Corrupt Organizations Act (RICO). The suit also questions Aetna's clinical policy bulletins used for retroactive denial of service.
"The scourge of postpayment audits by health insurers has become all too familiar to chiropractors across the country," said Dr. Sigmund Miller, executive director of the ANJC. "Indeed, insurance carriers continue to bombard chiropractors with refund requests demanding repayment of thousands upon thousands of dollars. Aetna, in particular, has been active in auditing and thereafter seeking recoupment from chiropractors."
The ANJC has retained Buttaci & Leardi and renowned class-action law firm Pomerantz Haudek Grossman & Gross, in filing the suit, which calls for nationwide relief on behalf of doctors of chiropractic and other health care professionals. Specifically, the suit seeks the following: to stop Aetna from continuing to engage in impermissible audit and recovery practices; to stop Aetna from enforcing clinical policies that are essentially baseless; compensation for chiropractors who have been coerced into making payments to resolve or defend against Aetna's unlawful overpayment actions; compensation for chiropractic trade associations that have devoted significant time and resources dealing with these various improprieties.
In a release from the ANJC announcing the lawsuit, the association provided more insight into Aetna's compensation practices and why the suit was filed:
"In addition to challenging Aetna's recoupment effort, the complaint challenges Aetna's excuses to justify its repayment demands. ANJC finds that a substantial portion of Aetna's justifications relate to chiropractic services that Aetna deemed - after the fact - to be experimental and investigational, such that they are no longer deemed to be 'covered services' under the applicable health care plans. Among other services, Aetna claims that the following chiropractic services are no longer covered because they purportedly have not been demonstrated to be safe and effective: Surface Scanning Electromyography ('SEMG'); Intersegmental Mechanical Traction; Electrical Stimulation; Activator and other Manipulative Devices (i.e., Proadjuster); Active Release Technique; Chiropractic Biophysics ('CBP'); Sacro Occipital Technique ('SOT'); Nerve Conduction Velocity ('NCV') studies; Manipulation under Anesthesia ('MUA'); and Aqua Massage (Dry Hydrotherapy). The action alleges that many of these services are generally accepted in the chiropractic community and chiropractors are entitled to provide such services and to be paid appropriate benefits under Aetna's plans."