Association of NJ Chiropractors Brings Class Action Suit against Aetna for Post Payment Audit Practices

The Association of New Jersey Chiropractors (ANJC), one of the largest chiropractic state associations in the nation, today announced that it has filed a lawsuit against Aetna seeking nationwide relief on behalf of chiropractors and other healthcare professionals.

The ANJC retained the law firm of Buttaci & Leardi, LLC, in concert with the renowned class action law firm of Pomerantz Haudek Grossman & Gross LLP, to investigate and file the lawsuit, which challenges Aetna s improper recoupment demands on chiropractors and other healthcare providers. The action alleges that Aetna s post-payment audit process is violative of the Employee Retirement Income Security Act of 1974 ( ERISA ), and further alleges that Aetna s post-payment audit process and its pre-payment claim review process violate the Racketeer Influenced and Corrupt Organizations Act ( RICO ). The action also attacks Aetna s clinical policy bulletins that are used to deny services retroactively.

The suit has been filed as a class action on behalf of all healthcare providers nationwide who have been harmed by Aetna s conduct. The ANJC has joined the action in a representational capacity on behalf of its members.

The scourge of post payment 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.

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.

The Complaint seeks: (1) to stop Aetna from continuing to engage in impermissible audit and recovery practices; (2) to stop Aetna from enforcing clinical policies that are substantively baseless; (3) compensation for chiropractors who have been coerced into making payments to resolve or defend against Aetna s unlawful overpayment actions; and (4) compensation for chiropractic trade associations, like the ANJC, who have devoted significant time and resources dealing with these various improprieties.

Counsel for plaintiffs are continuing to investigate these claims, and other related claims that may be added to the litigation.

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ANJC and Others Sue Blue Cross Blue Shield Association and Horizon Blue Cross Blue Shield of New Jersey for Post Payment Audit and Retroactive Recoupment Practices

Branchburg, NJ (September 11, 2009) – The Association of New Jersey Chiropractors (ANJC), one of the largest chiropractic state associations in the nation, today announced that it, along with the Pennsylvania Chiropractic Association ( PCA ), the New York Chiropractic Council ( NYCC ), and 15 licensed healthcare providers, including one ANJC member, has filed a class action lawsuit against the Blue Cross Blue Shield Association (BCBSA) and a number of state-based BCBS licensees ( BCBS), including Horizon Blue Cross Blue Shield of New Jersey, seeking nationwide relief on behalf of chiropractors and other healthcare professionals. The ANJC retained the law firm of Buttaci & Leardi, LLC, in concert with the renowned class action law firm of Pomerantz Haudek Grossman & Gross LLP, to investigate and file the lawsuit, which challenges BCBS s abusive practices in using flawed post-payment audits, improper repayment demands, and forced recoupments to recover substantial sums that have previously been paid as health benefits for services provided to BCBS subscribers.

Specifically, the lawsuit alleges that the post-payment audit process, as it is applied by the various named BCBS licensees, violates the Employee Retirement Income Security Act of 1974 (ERISA), in that the resulting repayment demands are retroactive benefit determinations that particular services are not covered under the terms of the BCBS health care plans, but without proper appeal or other protections otherwise available under ERISA for both self-funded and fully-insured health care plans offered through private employers. The complaint further alleges that these same post-payment audit practices, as well as the forced recoupments of unrelated health benefit payments to offset alleged prior overpayments, violate the Racketeer Influenced and Corrupt Organizations Act (RICO).

The suit has been filed as a class action on behalf of all chiropractors and other licensed healthcare providers nationwide who have been harmed by BCBS’s conduct. The ANJC, the PCA, and the NYCC joined the action in a representational capacity on behalf of their respective members while fourteen individual chiropractors and one occupational therapist, located around the country, have sued as the class representatives of the putative class. The suit was filed in U.S. District Court, Northern District of Illinois on Thursday, September 10 (Case No. 1:09-CV-05619). The ANJC and the NYCC had previously joined in a class action recently filed against Aetna, Inc., for similar post-payment audit abuses in federal court in New Jersey.

According to Dr. Sigmund Miller, Executive Director of ANJC, too many of our members had complained about these issues for us to do nothing. So we joined the PCA, the NYCC, and the individual doctors in bringing this lawsuit to put an end to an end to these abusive practices once and for all. One of the individual plaintiffs is an ANJC member.

The lawsuit seeks: (1) to stop BCBS from continuing to engage in impermissible audit and recovery practices; (2) to stop BCBS from retroactively enforcing clinical policies that are substantively baseless; (3) compensation for chiropractors who have been coerced into making payments to resolve or defend against BCBS s unlawful overpayment actions; (4) compensation for chiropractors who have had claim reimbursements forcibly recouped by BCBS on unrelated health benefit payments to offset alleged prior overpayments resulting from retroactive denials; and (5) compensation for chiropractic trade associations, like the ANJC, who have devoted significant time and resources dealing with these various improprieties by BCBS.

Counsel for plaintiffs are continuing to investigate these claims, and other related claims that may be added to the litigation.

If you have any questions, please contact Dr. Sigmund Miller, executive director for the Association of New Jersey Chiropractors by emailing drsigmiller@anjc.info or calling 908.722.5678.

About the Association of New Jersey Chiropractors

ANJC is one of the largest associations of chiropractors in the nation, with 1500 members, statewide. ANJC’s mission is to educate its members on the latest technology and advancements in the profession and to become a trusted, relied upon information resource to the public regarding the benefits of chiropractic care. For more information, please visit ANJC’s public information website at www.njchiropractors.com or call (908) 722-5678.