Among other things, the chiropractors are suing for:
- Claims that should have been processed by CIGNA prior to implementation of ASH that were not
- Delay in payment of claims in violation of the Tennessee statutory maximum;
- Unreasonable penalties, fees and charges against the claims made;
- Inconsistent advice from ASH/CIGNA customer representatives, resulting in delay of claims, incorrectly submitted claims;
- Untruthful statements made about provider's status as a capable provider made on patient Explanation of Benefits paperwork;
- Unreasonable and improperly denied claims;
- The implementation of a discriminatory review process that requires providers to submit additional documentation to a third party review process for medically necessary treatment of patients, when other similarly situated chiropractic physicians are not required to do so;
- The implementation of a discriminatory review process that requires providers to subject claims to a third party review process for medically necessary
- treatment of patients, when other similarly situated medical physicians are not required to do so;
- Improper bundling of claims;
- Inconsistent payments and denials based on erroneous information as to status as in-network or out-of-network;
- Inconsistent review mechanisms;
- Misrepresentation of benefits and copay amounts of patients to him, which were then relayed to the patient, ultimately to his detriment;
- Improper post claims denial;
- Improper assignment of a Tier program for claims made above the ASH mandated average, resulting in penalties to the provider in violation of law;
- Improper claims processing requirements for out-of-network providers; and the determination of medical necessity by a ASH peer reviewer in another state, who has not seen the patient, evaluated the patient, and who is not subject to the standard of care requirements for chiropractic physicians practicing in the State of Tennessee.
- Damages, loss of patients, an interference with the doctor/patient relationship, and monetary damages.
The Plaintiffs note in their filing that ASH was started in a two bedroom condominium in California in 1987.
American Specialty Health Incorporated (ASH) now promotes itself as a national health and wellness company that provides prevention and wellness services, specialty network management programs, and fitness and exercise services to health plans, insurance carriers, employer groups, and trust funds. Based in San Diego, ASH has more than 800 employees and serves over 25.9 million members.
