While Illinois politicians talk about the discomfort of
budget cuts and fiscal belt-tightening, George Perry can feel the pain in his
bones.
“The back problems come once a year or so,” says Perry, a 69-year-old Illinois state retiree.
There’s also the matter of his bum knees (both have been replaced) and a nasty case of tennis elbow that won’t go away. But now, after 35 years of state service, the former chemist says he’s been effectively cut off from his chiropractic and acupuncture therapy — the only forms of treatment that make him feel better.
Beginning in July 2002, Perry says his chiropractic insurance claims have been systematically delayed or denied by the state’s health plan administrator, the Cigna Corp.
“I’ve got 76 [claims] that are pending,” Perry says. “Eight were paid, and seven were denied.”
Perry, who lives in Springfield, says the backlog has become so habitual his chiropractor has begun charging him 100 percent in advance. Now, with out-of-pocket expenses totaling about $5,000, Perry can only wait for reimbursement checks.
He is not holding his breath.
“Cigna’s statement is, ‘We have requested more information before we can make a determination,’ ” Perry explains. “They just sit on them.”
Perry believes his difficulties over the last 18 months are a direct result of budget shortfalls at the state level. Cigna, his theory goes, has been given tacit instructions from the state’s Central Management System (CMS) to stall or deny all chiropractic claims.
“Part of it is just a delaying tactic, so the state doesn’t have to start paying money out,” Perry says. “But the other part is an outright attempt to deny claims.”
He’s not alone in his suspicions.
The Illinois Chiropractic Society (ICS), with over a 1,000 practicing members, says Perry’s problems are far from unique among state employees and retirees. And the ICS also agrees that their insurance woes bear a suspicious timing coincidence with the massive debt piling up in Springfield.
With an accumulated budget deficit of nearly $5 billion, nobody can fault state bean counters for cutting spending wherever possible. And healthcare costs — which have doubled since 1998 — are a rich target for the Office of Management and Budget. Last year alone, the state paid $818 million for health insurance, and that number is expected to rise by an additional $158 million this year.
But John Galbrath, past president of the ICS and a current board member, says chiropractors are unfairly taking the brunt of the healthcare fallout. “This all started when the money crunch settled in,” he recalls. “It seemed like chiropractic services were getting hammered a lot harder than some other professions.”
As Galbrath remembers it, his organization’s issues with the state started in 2000. He says Unicare Health — the third-party administrator between July 2000 and July 2002 — was the first to seriously question chiropractic claims. “They put an absolute clamp on it,” he says. “It seemed to have come down in a directive through CMS. Everybody’s claims were to be reviewed.”
Galbrath, who was president of the ICS at the time, held a meeting with CMS and Unicare early on. “They admitted that things were paid carte blanche before, but that was because [the previous administrator] wasn’t doing its job,” he says. “They said, ‘All we’re doing now is enforcing the rules of the plan as they were always stated.’ “
In a typical twist of bureaucratic confusion, the plan administrator that preceded Unicare in 2000 was none other than Cigna — now back for a second round. But no matter who’s processing the claims, Galbrath stresses that the state ultimately decides how freely to let the benefits flow.
“The [plan administrators] do what they are told to do,” he says. “The state gave an instruction that claims needed to be reviewed for necessity, for frequency and for diagnosis.”
Brian Woodard, a chiropractor in Carbondale, says the problem with independent insurance reviews is that the insurance company employs the reviewers. “They’re on their payroll, so how independent is that?” he asks. “If you let all the claims go through, you’re not going to be a reviewer for very long. Very rarely do I see a claim come back that agrees with everything we’ve done; you pretty well just expect that.”
Like most large organizations, the state has a wide variety of health insurance options from which its employees can choose. In a sign of the times, there are eight managed care programs, including some with different “tiers” of benefits. But the top-of-the-line model — and by far the most expensive for employees — is the Quality Care Health Plan (QCHP), a traditional indemnity insurance option that places virtually no limits on the providers and hospitals beneficiaries may use. Although CMS controls the checkbook for QCHP, it awards contracts to private insurance companies — currently Cigna — for administration and claims processing.
As a QCHP enrollee, George Perry should, in theory, be able to go to any licensed chiropractor in the state and receive 80 percent reimbursement for all covered charges. His out-of-pocket expenses for any given year (not counting an annual $200 deductible) should be no greater than $800.
But historically, nothing about chiropractic medicine has been clear-cut. Even today, with over 50,000 licensed practitioners in the U.S., the scope of chiropractic validity is still disputed. Some chiropractors believe that “manipulative procedures” are useful only for joint, nerve and muscular dysfunction — and then, only for the parts of the body actually being manipulated. Others stick to the original chiropractic hypothesis, holding the view that skeletal misalignment is the root cause of all disease.
For insurance carriers, however, the only salient point is whether the patient is making progress toward a resolution. Galbrath says companies will only normally pay for treatments that can reasonably be expected to end — and the sooner, the better.
“A patient is supposed to be discharged,” Galbrath explains. “If the documentation does not show that the patient is getting better, they are at a condition known as permanent and stationary, and usually that’s when the insurer stops paying.”
Nicole Grady, a spokesperson for CMS, says state coverage ends once medical documentation indicates that maximum medical improvement has been achieved. “The coverage ends when it becomes a maintenance issue,” she says.
But Woodard says the insurance reviews are more dependent on what he calls the “magic number” — the amount of visits a patient accumulates — then they are a patient’s progress. “Once you hit that number, they ask for records,” Woodard says. “Of course, they won’t tell you what that number is.”
If there is such a number, Perry undoubtedly hit it long ago. In addition to his back, elbow and knees, Springfield chiropractor and acupuncturist Louis DiStasio has treated Perry for breathing difficulties following open-heart surgery, Bell’s palsy and high blood pressure.
“Things seem to pile up,” Perry chuckles.
DiStasio declined comment, but listening to Perry one senses there are few ailments DiStasio cannot treat either by lining up the skeleton or stabbing the skin with needles. At its peak, Perry was seeing DiStasio three times a week at $75 to $100 per session.
“All of these things were covered [before],” Perry says. “I always got paid.” The dramatic shift in policy Perry describes is, in fact, what irks him the most: “Everything just changed overnight. I haven’t done anything extraordinarily different this year than I have in years past.”
Acupuncture, of course, is even less accepted in some circles than chiropractic. Ironically, for insurance purposes acupuncture patients must not improve in order to be reimbursed. According to the QCHP benefit summary, acupunctural sessions are reimbursed at 80 percent of usual and customary charges for “treatment of chronic pain.”
Thus, practitioners such as DiStasio are seemingly caught in the crossfire: for chiropractic care, the patient must have an acute condition and show signs of progress; for acupuncture, the patient must be in constant pain and never get better.
For its part, Cigna says it’s doing nothing differently now than it always has. “We’re applying the same criteria to the claims as we have since July 2002,” says Patty Caballero, a spokesperson for Cigna. Those criteria, Grady adds for CMS, are identical to the ones Unicare applied when they ran the system.
Perhaps. But in Carbondale, Woodard (who does not practice acupuncture) says all of this is taking a serious toll on his business. Thirty percent of his patients are state employees, and already there have been cuts in his staffing levels. “The state has been behind for years in paying the claims,” he says. “We can go two to five months without payment, but can you tell me any state employees in Springfield who go over two weeks without a paycheck?”
Grady, the CMS spokesperson, doesn’t deny that something called a “claim hold” has been put in place. “It’s typical that claims are held,” she says. “But it doesn’t mean they’re not being paid.”
State Senator and Assistant Minority Leader David Luechtefeld, R-Okawville, says none of this is shocking or new. “I’ve dealt with [chiropractic claims] for years,” he says. “For the last three or four years, in particular, they have been very difficult to get to move.”
Luechtefeld acknowledges the difficulty in separating the legitimate claims from ones that go overboard. Unfortunately, he’s noticed a trend: “Usually they seem to err on the side of not paying. It really is like pulling teeth.”
Like Galbrath and Woodard, Luechtefeld maintains that chiropractors are being singled out for extra scrutiny. “I’m sure they question all kinds of claims, it’s just that they do it more often in this area,” the senator says.
Not only is this special treatment unfair, Galbrath and Woodard both allege it’s also illegal. Under the Illinois Medical Practice Act of 1987, they say discriminating against any class of physicians — defined as medical doctors, osteopathic doctors, and chiropractors — is unlawful.
“We’ve seen time and time again where patients are allowed 60 visits a year for physical therapy, provided by physical therapists. There’s very little scrutinizing of that,” Woodard says. “Yet we provide 20 visits for a patient and all of a sudden that red flag hits and they’re demanding records.”
Woodard says chiropractic medicine is a different ballgame from medical practice. Most medical doctors, he says, will see a patient two or three times for a particular ailment before referring them to another specialist. Chiropractors, by comparison, practice “physical medicine,” which can only change the body through repetitive treatment.
What galls Woodard is the lack of face-to-face interaction between the insurance reviewers and his patients. “Anybody can say records aren’t good enough, or it’s not medically necessary,” he says. “But how can they document that if they’ve never seen the patient? For them to tell me that a patient only needed 16 visits, where do they get off doing that? They didn’t see my patient, they don’t know how much they were hurting when they came in, and no one heals at the same rate.”
For those who have the time and patience, the state offers a three-appeal process. But Woodard says the establishment is banking that most people will not take the time or expend the energy to take them up on it. And even if they do, the three- to six-month appeal process can cause major setbacks, he says.
“You can’t afford to stop your care if you’re going to make progress,” Woodard says, adding that most patients who receive warning notices will stop getting treatment. “People living from month-to-month, all the sudden they get a letter from Cigna saying we’re going to review your claims and they might not be paid anymore — what do you think? That to me is interfering with the doctor patient relationship.”
More interference in the healthcare field is the last thing state retirees say they need right now. Indeed, the insurance horizon is already tilting steeply with the recent enactment of a Medicare prescription drug program, scheduled to take effect in 2006.
Lee Fuchs, a director for the Retired State Employees Association (RSEA), says his membership is concerned by the lack of details in the plan. “There’s so much to be filled in yet,” he says. “We have a drug plan now for retired state employees. We’re concerned that the state might say, ‘Since there’s coverage under Medicare, you can just all go under there now.'”
Fuchs says such a move would be disastrous for his membership, because the Medicare plan could cost recipients thousands in out-of-pocket expenses. On top of that, Gov. Rod Blagojevich has devised a plan to import less expensive drugs from Canada. With permission from the U.S. Department of Health and Human Services, he claims the state could save about $91 million annually from its $340 million drug bill.
Although this change by itself might not harm retirees, Blagojevich’s threat to punish drug manufacturers who limit drug shipments to Canada is a different story. “Let’s say you’re taking heart medication by a particular manufacturer,” Fuchs says. “If Blagojevich removed that manufacturer from the state’s preferred list to get drugs, that would mean you could have to find some other medication.”
Luechtefeld says he hopes the chiropractic problems don’t spread to other areas of medicine. But one thing he is not worried about is Blagojevich’s Canadian drug proposal.
“I think that’s just another news release,” he says with a laugh.
As for George Perry, he suspects his out-of-pocket expenses are long gone — yet it’s the principle that bothers him the most. “My main outrage is not so much losing the money, but with how the state is getting away with fleecing so many participants in the state health plan,” he says.
“They’re diverting millions of dollars to deal with financial problems caused
by politicians.”
This article appears in Jan 22-28, 2004.
