The Institute, founded in 1998, provides a facility to promote health research in natural means. This Fundly crowdfunding program is intended to provide support for holistic practices and practitioners - www.InHeRe.org
The litigation involving the New Jersey natural doctor has continued since the last update. We are close to achieving an accommodation with the insurance carrier that may benefit all natural doctors.
Here is some of what the defense is planning to tell the court:
8. The insurance carrier is obligated under Federal law to engage in what the relevant Federal Agency (Center for Consumer Information & Insurance Oversight - CCIIO) says must be “good faith” and “reasonable” steps to meet the Provider Nondiscrimination Provision of the Affordable Care Act, codified in the Public Health Services Act (PHS) as section 2706(a), with regard to the claims submitted by defendants that plaintiff denied. https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs15.html
9. On the record in this case, there is no evidence that the plaintiff engaged in any “good faith” or “reasonable” steps to adhere to the Provider Nondiscrimination provision. That provision of the law, Section 2706, states: “a group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable state law.” The question of the plaintiff’s good faith and reasonable actions is a question for the trier of fact and there must be a preponderance of the evidence to show that the plaintiff so acted.
10. Since the basis for the plaintiff’s claim that it is not obligated to cover its customers’ treatments when there is an alleged failure to meet certain technical requirements of the corporate practice of medicine, which is a remedy that is not provided in the statute, the remedy sought is essentially an equitable remedy. However, to receive equity from the Court the plaintiff must do equity. The plaintiff has failed to do equity by failing to abide by the provisions of the Provider Nondiscrimination provision and by failing to meet the Unfair Methods of Competition standards provided in N.J.S.A. 17:29B-4, as discussed below.
11. The Unfair Methods of Competition law clearly includes health care insurance, in that health care insurance is mentioned at least twice in the law by way of inclusion, not exclusion. The assertion that the law does not apply to the plaintiff is not supported by the language of the statute.
12. (2) Among other provisions of law and regulation, Horizon is obligated to remain in compliance with the following provisions of N.J.S.A. 17:29B-4, Unfair methods of competition, unfair, deceptive acts, practices, defined (which is appears to have violated):
13. Clause (9) (c) - Failing to adopt and implement reasonable standards for the prompt investigation of claims arising under insurance policies;
14. Clause (d) - Refusing to pay claims without conducting a reasonable investigation based upon all available information;
15. Clause (e) - Failing to affirm or deny coverage of claims within a reasonable time after proof of loss statements have been completed;
16. Clause (l) - Delaying the investigation or payment of claims by requiring an insured, claimant or the physician of either to submit a preliminary claim report and then requiring the subsequent submission of formal proof of loss forms, both of which submissions contain substantially the same information;
17. Clause (m) - Failing to promptly settle claims, where liability has become reasonably clear, under one portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage;
18. Clause (n) - Failing to promptly provide a reasonable explanation of the basis in the insurance policy in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement;
19. Clause (10) - Not attempting in good faith to effectuate prompt, fair and equitable settlements of claims in which liability has become reasonably clear.
20. Based on our review of the documentation between S. Jonuzi’s management company and Dr. Gardner’s medical practice company, including the contracts and the Standing Order, we conclude that there was a good faith effort by both companies to structure their relationship to meet New Jersey’s standards for the corporate practice of medicine. The plaintiff has however failed to do equity and is barred from what it claims is its equitable remedy.
Notes from my recent conversation with an Insurance Code expert:
Right before former President Obama was elected, Big Pharma was spending $600K a day on lobbying Congress. To see the 2018 lobbying spend by company, see: https://www.opensecrets.org/lobby/indusclient.php?id=h04
Why is this money impacting every one of us? Because it's easy to get "health care" as long as you see pill pushers or go to a hospital but you have to pay out of pocket if you want actual therapies that are not invasive and don’t rely on drugs and surgery. You could have this care without seeing a physician if there were codes to file insurance claims.
Big Pharma supports prescribers – not healers. The medical device industry is supported by hospitals and ongoing health problems – not by solving health problems. Big insurance prices insurance premiums at a minimum of 25% over expected claims – so it is not focused on saving money. This system intentionally keeps consumers in the dark according to Forbes: https://www.forbes.com/sites/danmunro/2013/02/11/healthcares-pricing-cabal/#5a3f3bd26700
The government has mandated the entire industry use codes designed by and for physicians (known as CPT) which are developed by the AMA. But if you read the link the Forbes article, you will also see that the AMA developed the pricing for its coding system.
CPT codes have even more influence on government policy than just being named a mandatory standard. CPT is also known as HCPCS I. HCPCS II codes are developed by the Centers for Medicare and Medicaid Services. By contract with the AMA, HHS agreed to retire any HCPCS II codes that may duplicate CPT. The AMA got this monopoly by giving Medicare and Medicaid a free license for use of its codes. Every insurer, hospital and health provider in the country must pay licensing fees or royalties to the AMA for use of its codes. This generates anywhere from $70 - $150 million a year in revenue for the AMA – as stated in the Forbes article referenced above, the AMA effectively hides its CPT revenue by lumping it in with other products and services.)
What can we do about it? For one, make sure that Section 2706 of the Affordable Care Act is not pulled but instead, given sharper teeth. Imagine if insurers were forced to pay for drugless and non-invasive therapies from any licensed health professional. You would not have to go to a physician to get diagnosed and sent home with a pharmaceutical. Your nurse practitioner could see you without having to follow the rules of being a physician extender. You could visit a massage therapist to reduce your stress or treat a tight muscle without having to take muscle relaxers or Prosac. You could see a holistic doctor and get a vitamin or mineral IV therapy to enhance your immune system rather than be prescribed yet another round of damaging antibiotics – which were the initial cause of your immune system’s failure.
All the evidence suggests if Insurance Companies did as their Premium-Payers wanted, and covered holistic and integrative therapies, their bottom line would benefit significantly.
The case survived a Summary Judgment Motion and will continue to test the limits of the ACA's Provider Nondiscrimination provision. http://www.inhere.org/2018/12/14/great-strides-in-the-case-for-alternative-providers-in-new-jersey/
Great News! Nestor Smith, the attorney for the Defendants appeared in court yesterday on Horizon's motion for summary judgment. The court denied the motion which means that the issue of Provider Discrimination clause of the Affordable Care Act is still in court and this case could change the way insurers have to pay for integrative and holistic care!
Just posted this at the Institute web site.
Our first Crowdfunding project involves pending litigation that can construe the Affordable Care Act to forbid insurance carrier discrimination against holistic and integrative practitioners, permitting proper insurance coding for such therapies, and, from the standpoint of the Mission of the Institute, facilitating retrospective research into holistic and integrative modalities (through coding statistics.
We are having a great early response to this crowdfunding effort! Our article about it has been posted at:
You can read it here:
And please, please, please share this Fundly link with everyone! https://fundly.com/support-natural-therapies
Thanks for our first donation! Thanks to The Bolen Report for posting this article: http://bolenreport.com/we-need-to-get-real-health-care-paid-for/
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