Written by Deborah Sherman
The company, Columbine Health Plan (CHP), says it's allowed to operate that way in a special deal with two of Colorado's largest health insurance companies, Kaiser Permanente and CIGNA Health.
CHP bills the insurance companies on behalf of 350 chiropractors in Colorado. While CHP admits the way it does business costs some patients more money, overall, it claims to save health care dollars.
"I'm paying more than I should be," said Susan Havekost of Fort Collins, who regularly sees a chiropractor. "It doesn't make any sense."
When Havekost got her explanation of benefits from MVP Health Plan, which is administered by CIGNA, it looked like her chiropractor had been paid $61 for each visit, instead of $36 he said he charged.
When she called, Havekost learned the third-party administrator CHP has been increasing her doctor's bills and submitting them to CIGNA, which has been paying the higher bills.
"Should Columbine be doing this? Is it ethical?" Havekost asked. "To me, it's not right."
The up-charging is draining Havekost's annual flexible spending account. With CHP marking-up her bills 69 percent, she and others like her are losing nearly half of their annual visits to the chiropractor.
"They're not getting what they paid for. They paid for a policy that pays $500 worth of chiropractic coverage, but it's being exhausted very fast by a third-party administrator that does nothing much more than shuffle paper around," said Dr. Greg Crawford, board member of the Colorado Chiropractic Association (CCA) and a member of CHP. "It doesn't happen once in a while. They change our fees on most charges every single time."
9Wants to Know has learned CHP also adds services to doctors' bills that were never performed on patients.
"They changed a calf stretch to a spinal manipulation," said Dr. Mike Springfield, CCA president, who reviewed health records for 9NEWS. "If you're not billing for what you're doing, it could cause a tremendous amount of accounting nightmares. You need to bill for the things you do. That's just common sense."
9Wants to Know reviewed bills for nearly 50 patient visits and found CHP increased fees or added services every single time.
Owner David McReynolds started CHP in 1994. He has contracts with Kaiser Permanente, CIGNA Health and the Denver Health Medical Plan to access his network chiropractors who provide services to more than 500,000 Coloradans.
In a letter from McReynolds' lawyers to 9NEWS, he said "CHP does not charge patients for services that were not rendered."
According to McReynolds' counsel, CHP corrects codes when chiropractors have used them incorrectly.
On May 24, avid sportsman Jeremy Hayes, who makes frequent trips to the chiropractor, allowed 9Wants to Know to videotape Crawford adjust areas of his spine and give him an electrical stimulation treatment.
9NEWS then videotaped Crawford charging Hayes $36 for the spinal treatment and $19 for the electrical muscle stimulation. Crawford sent the bill, which totaled $55, to CHP for processing.
Once CHP received the bill, it increased the cost of the spinal manipulation 69 percent from $36 to $61 before submitting the bill to CIGNA. CHP billed CIGNA $80, which is $19 for the electrical stimulation and $61 for the spinal, according to Hayes' explanation of benefits from CIGNA.
CIGNA paid CHP $46 for the spinal manipulation, which together with Hayes $15 co-pay, was the $61 that CHP had charged. Records show Columbine's kept $16, or 35 percent.
9Wants to Know shared the results with Hayes after reviewing the doctor's bill, his explanation of benefits and the statement from CIGNA.
"I'd like to know what's going on," Hayes said. "It seems a little strange that extra money is being tacked on, and when you look at the bill, you have no idea that it's being tacked on."
"It's important to not gouge the system and I think that's what's happening here," Crawford said. "Managed health care organizations are designed to save money for the health care system, and in this case, it's increasing the cost."
Another chiropractor says so many of his Kaiser Permanente patients came into his office angry about the difference between his actual bill and their explanation of benefits, he drew up a form to explain why their insurance benefits don't make any sense.
Benefit statements from Kaiser patients show Dr. Mike Simone was paid $180 per back adjustment, when his bills show he charged $45.
"It looks like the money is coming to me, but it's not," Simone, of Dacona, said. "I do wonder if I've had some patients who have gotten their statements and thought I was paid $180 and didn't come back. That is sort of the fear I have."
Doctors say they didn't know CHP was adjusting their bills until patients complained. Statements from CHP to doctors do not reveal that fees have been increased and services added.
CHP increases fees and adds services to the chiropractors bills, then sends the altered bills to CIGNA, according to statements CIGNA sends to patients.
In the bills reviewed by 9Wants to Know, CHP's changes make most doctors' bills appear more expensive to CIGNA than they actually were.
McReynolds says he doesn't inform patients about the changes because his contracts with the insurance carriers are confidential.
"We have a relationship with the insurance company that doesn't affect the doctors," McReynolds said. "What's on the bills is irrelevant because we have a contract to get paid that way."
Chiropractors in the CHP network receive $45 per visit, minus the patient co-pay, if any, regardless of the number of services they perform on patients. Participating doctors sign contracts agreeing to those terms. McReynolds makes money by charging CIGNA $61 per visit, which is a pre-agreed upon flat rate.
In his contract with Kaiser, McReynolds says he's paid about $220 per patient for an unlimited number of visits to the chiropractor. Records show CHP keeps almost half of the $220, or about $110 for "administration fees," and sends the rest to the chiropractor. The chiropractor gets paid $110 once, plus the patient's co-pay, whether he treats them once or 20 times a year, according to doctors.
"When Kaiser patients come in the office, the lights go out," Dr. Bernard O'Grady, of Englewood, said. "You don't want to treat them."
McReynolds says CHP keeps health insurance affordable because, on average, chiropractic bills are more than $61 per visit.
In 14 of 50 visits reviewed by 9NEWS, the doctors' original bills were higher than the $61 payment from CIGNA to CHP.
"These contractual relationships are voluntary, legal, above-board and transparent," wrote McReynolds' legal team in response to questions. "Columbine's case-rate system frequently results in the provision of more-not fewer-chiropractic services."
Before CHP, old insurance bills show doctors who negotiated directly with CIGNA were paid $45 on average. After CHP, CIGNA has been paying $61 per visit.
McReynolds says insurers outsource to his company because CHP can bill "more efficiently and effectively" than CIGNA and Kaiser could without a network of chiropractors.
When asked why McReynolds added codes that represent different treatments performed on patients, he first blamed it on CIGNA's payment system, which he said did not read certain medical codes.
"We do it to trigger the system to pay," McReynolds told Investigative Reporter Deborah Sherman.
Later, in a letter , McReynolds' attorneys explained that codes are changed sometimes when doctors "...fail to utilize the proper codes in their billings."
McReynolds says he only changes service codes 2 percent of the time. McReynolds also says he has "the express permission of the carrier" to change service codes to make the system pay out the benefits.
In the letter from his lawyers, McReynolds claims CHP calls each doctor's office to confirm that the services, which CHP added, were actually performed by the doctor.
"Only when it has confirmed that the insured has actually received such services will it add the CPT code to an insured's bill when it submits it to the carrier for payment," wrote McReynolds' attorneys. "Ms. Sherman's notion that the added CPT codes are fraudulent entries for unperformed services is wholly without factual basis."
However, of 10 doctors interviewed for this story, none have ever been called by CHP before it increased the fees for their services or added treatments that they never performed.
"On no occasion in 10 years were our offices contacted by CHP employees to reconcile a claim where a service was added. The services were added without our consultation, knowledge, or approval. No documentation in our patient records exists that the service was provided to the patient because it in fact was not. This assertion that a billing error occurred in the provider's office or that the provider had something to gain by adding the service is false," the doctors said in a unified statement to 9NEWS.
Other third-party administrators that manage a network of doctors like CHP don't alter patients' bills.
"I can't imagine any insurance company that allows someone to do that, to touch or manipulate the bills. You can't change those things... because you're using up patient benefits or health savings account funds that the patient has paid for," Mike Nehring of Capstone America, which represents 250 chiropractors throughout the state, said.
Capstone Chiropractors submits doctors claims directly to contracted insurers that are paid, according to a fee schedule the doctors have agreed to accept as full payment of services, according to Nehring.
Capstone charges the insurers a 4 percent administrative fee on paid claims and do not charge the doctor nor take money from patients, Nehring said. In comparison, CHP's average profit is 26 percent per visit, according to bills reviewed by 9NEWS.
McReynolds won't say how much his for-profit company earns. In August, a listing on the business website Manta.com estimates his annual revenue at up to $2.5 million a year.
Property records show McReynolds owns three properties, including a house in Aurora, a horse farm in Fairplay and a vacation home in Scottsdale, Ariz.
McReynolds is also a big campaign contributor. Secretary of State records show McReynolds and his companies have donated more than $213,000 to Republican campaigns and causes.
On June 16, 2005, Gov. Bill Owens (R-Colorado) proclaimed it "David McReynolds Day."
CIGNA Health and Kaiser Permanente sent brief statements to 9NEWS.
"We negotiated a contract that we believe serves our members' care needs," Amy Whited, senior media relations for Kaiser Permanente Colorado, said. "We review all of our contracts with third-party care providers and negotiate changes when appropriate."
"We maintain that the per-visit rate we negotiated with Columbine is competitive for chiropractic services in Colorado," Mariann Caprino, vice president of corporate communications for CIGNA, said. "We are looking into the situation with Columbine Health Plan and will take corrective action if we find anything inappropriate or inconsistent with our contract."
Several chiropractors and patients have complained to CHP, CIGNA Health, Kaiser Permanente, Colorado Chiropractic Association and the Colorado Department of Regulatory Agencies (DORA). But the practice of adjusting bills has continued since 2002 when CHP struck a deal with CIGNA.
Some doctors told 9NEWS they're afraid to complain because of a special paragraph in their contract with CHP which says they could be fined $5,000.
DORA says it has no regulatory authority over any third-party administrator or network manager in Colorado because the companies are not licensed.
Chiropractor John Hanks, who was the medical director for CHP, sits on the board of the Colorado Board of Chiropractic Examiners which oversees "issues of importance to the chiropractic profession," according to its website.
The board has not considered any complaints received by the DORA. Hanks, who knows about CHP's practices as its former medical director, did not return calls for comment.
The Colorado Attorney General's office, which has received recent complaints, can investigate ethical violations and/or illegal billing practices. Doctors tell 9NEWS Attorney General investigators are reviewing complaints about CHP.
While doctors have a signed agreement or an "assignment of benefits" with patients to collect their insurance benefits proceeds, third party administrators like CHP do not have patients' permission to bill insurers.
The Colorado Chiropractic list serve polled CHP members and found most chiropractors would prefer to deal with insurers directly instead of working through CHP.
9Wants to Know wants to know what you think about this story. Please email Investigative Reporter Deborah Sherman at Deborah.Sherman@9NEWS.com.
No comments:
Post a Comment