Making Health Insurers Comply with Provider Non-Discrimination Legislation…
Opinion by Ralph Fucetola JD
What if it was possible to make insurers stop denying claims for legally delivered alternatives to conventional medicine today?
What if doing this would also address rising healthcare costs?
With your help, we intend to attain these two goals by leveraging the legal defense for a provider who is otherwise going to be crushed by a Blue Cross Blue Shield Plan (that plan is Horizon).
It is our belief that the fastest way to force insurers to comply with existing law is to win a lawsuit against one…
But before we explain this further, it is important to understand why alternative treatments are not being paid for by insurers in the US, even when they are less costly and more effective than conventional medicine.
To begin, the insurers claim there is “no data” to show which alternatives to conventional medicine work. Why no data? Computers read codes to generate data about healthcare treatments. There are very few codes to communicate alternative treatments to insurance companies. Without codes, there is no insurance claim. Without a claim for reimbursement for healthcare services, there is no cost for a computer to compare by diagnosis.
How did this happen? The government began mandating the use of the American Medical Association’s CPT codes around 1988, primarily because it was the only coding system widely used at that time to process claims for medical care. In 2000, the AMA’s codes were also mandated for electronic insurance claims, even though there were other code sets available then, too. The AMA is a physician trade organization which does not offer membership to non-physicians.
as much sense as the government putting Ford in control of developing service and supply codes for GM. However, that is just what the government did with healthcare coding.
The AMA’s healthcare service codes often are structured so that only a conventional doctor can legally use the code. This, in turn, frequently requires conventional physicians to oversee other health professionals – even though these health professionals are licensed to manage care without oversight. This type of business challenge applies to over 2 million health professionals. Many practice under a physician to avoid the hassle of filing insurance claims.
Paying physicians to oversee work provided by advanced practice nurses, behavioral health providers, physical and occupational therapists, chiropractors, massage therapists, acupuncturists, midwives, naturopaths and more is often not needed and creates unnecessary bottlenecks in care delivery.
There is light at the end of this tunnel:
The Affordable Care Act was passed in 2014. Section 2706 of this law prohibits health insurance payers from discriminating against health providers who are acting within their legal scope of practice.
Unfortunately, legal precedent has not yet established the scope of this new law.
In its broadest interpretation, any provider who is qualified to provide therapy for, say, low back pain cannot have their claims denied if the insurance company would have paid a doctor for low back pain treatment.
We have established a crowd funding site to support insurance company compliance with this law and to assure it has the broadest impact possible.
Experts are already consulting with a provider in New Jersey who is being sued by Horizon Blue Cross Blue Shield. Without outside support, the provider is going to have to file bankruptcy just to respond to the enormous amount of legal paperwork being generated by the insurer’s lawyers.
Your help can make all the difference.
If this message is taken to heart, a powerful crowd funded war chest will be built from your donations to protect any provider who is being discriminated against by an insurance company.
Every provider in the country who is not practicing conventional medicine would benefit if this provider wins the Horizon lawsuit. Typically Insurers target integrative and holistic practitioners with multi-million dollar “fraud”
law suits, aimed at shutting them down.
However, just $5 from a million providers and users would create a legal defense fund of $5 million. Having a legal fund already in place will deter other bad actors in the insurance industry from bullying providers.
The AMA has immense lobbying power because it generates between $70 – $100 million in revenue from its CPT codes each year. However, there are 3 million non-physicians and only 700,000 MDs. You – the alternative health care providers and users — can stand up to this monopoly if you join forces.
The courts have the authority to protect patients’ rights to reimbursement but this type of suit is usually very expensive. And the threat of “fraud” triple damages deters the targeted practitioners’ defense, leaving the public defenseless against Insurer power.
Without your help, the integrative health care practice being sued by Horizon will be destroyed because Horizon can afford the top-priced, tough – and mercenary — legal talent. The doctors and practitioners being sued by Horizon cannot hope to match their power but they can win with your help.
Most targeted providers give up and give in but these providers are willing to fight and their attorney and their experts believe Horizon has a very weak case. If these defendants succeed, this case will set a precedent that requires other insurers to play fair.
We are optimistic that Horizon Blue Cross Blue Shield can not only be stopped but also punished for violating Section 2706 of the Affordable Care Act.
There are 18 legal mistakes that Horizon’s lawyers are hoping to cover-up. We detail them at the Fundly crowd funding web page. Go there now to find out the Insurance Monopoly’s legal jeopardy: https://fundly.com/support-natural-therapies
These important issues will not be heard by the court without sufficient funding.
All funding will be held by a tax exempt, non-profit organization, the Institute for Health Research to be to defend providers — and patients — against discrimination under section 2706 of the Affordable Care Act and to support natural therapies.
Please go to https://fundly.com/support-natural-therapies to donate today. It’s that “giving time of year” and this is a cause well-worth your support! Motions to suppress the practitioners are pending. We must act now.
Opinion by Ralph Fucetola JD
Ralph Fucetola, JD, President
Institute for Health Research
PS – please forward this plea to all your circles of influence: https://fundly.com/support-natural-therapies