Profession Can Now Pursue Alleged ERISA Violations
The American Chiropractic Association (ACA) today announced that it, along with other plaintiffs in a class-action lawsuit against UnitedHealthcare (United), defeated a motion to dismiss the case.Among co-plaintiffs in the litigation are the Congress of Chiropractic State Associations (COCSA), the Missouri State Chiropractors Association (MSCA) and the Ohio State Chiropractic Association.
The decision by the U.S. District Court for the District of New Jersey upheld the validity of the plaintiffs' central, underlying claims against United and its co-defendants, including the inappropriate recoupment of reimbursements previously paid to providers. At times, the money is recouped from patient accounts that are not actually involved in the alleged overpayment – a clear violation of ERISA.
The defeat of the defendant's motion to dismiss now allows plaintiffs to pursue injunctive relief for the inappropriate and abusive practices long fought by the chiropractic profession, which have restricted patient care and, the profession believes, harmed the careers of doctors of chiropractic. These practices include:
- In violation of ERISA, appeal rights have been inconsistently afforded to patients when the care authorized differs from the doctor's care plan.
- In a deliberate effort to avoid its obligations under ERISA, Optum, a co-defendant in the case, refuses to allow providers to request a particular number of visits or procedures, or to submit adequate clinical information necessary for utilization review.
- Providers are subjected to threatening communications in an effort to pressure them to reduce utilization rates.
- Optum relies on statistically invalid data to determine average utilization rates. It further manipulates data and pressures providers to reduce care, thereby over time continually reducing what is reported as the "community standard" for proper levels of care.
- Even though doctors only provide the services pre-authorized by Optum, the network continues to declare the averages derived from those authorizations inappropriate and they pressure providers to further reduce care.
"The court's decision to reject United's motion to dismiss is a groundbreaking victory for doctors of chiropractic and their patients across the country. The profession's cries for an end to United's attempts to intimidate and coerce patients and providers have been heard and validated in a court of law," said ACA President Keith Overland, DC. "Plaintiffs are now free to continue their fight for their patients' rights to receive medically necessary care, and to hold insurers accountable in respect to reimbursing providers for care patients have paid for through their insurance premiums."
"This decision is a multi-faceted victory for the profession," said COCSA President Kate C. Rufolo-Dreher, DC. "It is an important step in this particular lawsuit, and the action taken in the litigation to date marks an extremely important step for the profession and the patients we care for."
The litigation, filed on Jan. 24, 2011, represents a nationwide class of health care providers who were subjected to United's improper recoupment of payments for services provided to United subscribers. ACA joined the lawsuit in April 2011.
The court's decision also allows plaintiffs to move forward to class certification, the next step in this landmark litigation for the profession.
Source: American Chiropractic Association