CalChiro has communicated previously that health plans are changing their Medicare Advantage administrative and clinical policies/procedures as well as updating their electronic platforms.
One specific health plan – Humana – now requires pre-authorization submission for delivery of services provided by doctors of chiropractic and other services provided by other categories of providers. CalChiro has engaged in discussions with upper management of Humana, and these representatives agree with our position of pre-authorization potentially causes delay in care. Humana claims that current federal regulations require this service and therefore they must comply. The complication of this process is that American Specialty Health is the delegated entity in California that manages this benefit for Humana. CalChiro has met with Senior Management at ASH, and their process of requiring submission of treatment forms for authorization has not changed. In other words, ASH contracted providers will submit treatment requests based on their assigned tier levels. CalChiro has been assured that no changes has occurred with respect to the clinical submission process.
CalChiro also received a response to its letter to UHC that manages Medicare Advantage benefits for a variety of organizations, including AARP. The response essentially outlined the information CalChiro is aware of and did not offer any information that necessarily clarifies their position. There does not appear to be visit limitation – only the submission for pre-authorization for services provided after the initial evaluation. CalChiro will continue to work with ChiroCongress and the ACA on this matter.
CalChiro continues to receive inquiries from members related to Anthem’s administrative and reimbursement inaccuracies related to the providers status. As we noted in prior communications, CalChiro has not received any communication from either ASH or Anthem related to our September 2024 letter. As CalChiro noted in the letter, if no response was received, the DMHC would be contacted and grievances would be filed and that has occurred. Additionally, CalChiro members have submitted providers appeals to the DMHC. CalChiro is not aware of the status of these submissions. However, CalChiro did meet with the ASH Senior Management in November to discuss this issue. ASH delivered substantial proof that their compliance as required by the DMHC as well as the delegation requirements have been met. Anthem has been in the process of revamping their electronic platform and has not been able to manage the day-to-day updates from the electronic submissions by ASH as required noted above. CalChiro’s letter and provider complaints demonstrate that Anthem is in non-compliance of DMHC requirements and CalChiro will amend the initial filing to outline these new findings. CalChiro encourages providers that receive inappropriate payment (OON reimbursement) in spite of being a contracted provider should submit appeals to the DMHC. With a “flood” of complaints, DMHC action will be stepped up.
CalChiro recognizes the issue related to Multiplan and we remain in the process of the best avenue to explore resolution in CA. Multiplan is multi-state and CalChiro has had conversations with other chiropractic associations related to this topic.