Naturopathic Doctors and Patients File a Class Action Lawsuit Against Health Net Plan of Oregon and Ash Network

 In Naturopathic News



Lawsuit Cites Unlawful and Discriminatory Practices that Limit Access to Benefits

PORTLAND, ORE., JULY 7, 2015 –Today, the Oregon Association of Naturopathic Physicians (OANP) filed a class action lawsuit in federal court against Health Net Health Plan of Oregon, Inc. (Health Net) and their contracted benefits provider American Specialty Health (ASH), alleging unlawful and discriminatory practices.

The lawsuit was filed on behalf of naturopathic physicians and their patients who allege that Health Net discriminates against Oregon licensed naturopathic physicians by denying claims for services provided by Naturopathic Doctors (NDs) that are otherwise covered when delivered by a different medical provider. The “Non Discrimination in Health Care” section of the Affordable Care Act (ACA), commonly known as “Section 2706” (42 U.S.C. § 300gg-5), prohibits insurance carriers from discriminating against health care providers acting within the scope of their license.

Lawsuit plaintiff and Health Net participant Eileen Fox-Quamme experienced the medical care limitations caused by Health Net’s discriminatory practices first-hand. On October 27, 2014, a Health Net-contracted naturopathic physician saw Fox-Quamme for a routine preventative medical care visit, a service that all insurers are legally required to cover. Health Net’s subcontractor ASH, which provides contracting and claims processing for all Health Net “complementary providers,” including naturopathic doctors, denied her claim on November 4, 2014. After exhausting Health Net’s grievance process, in February 2015 Fox-Quamme submitted an appeal of the denial through the law firm Bennett, Hartman, Morris & Kaplan. One month later, she received a letter from Health Net stating that while her claim had been correctly denied by ASH, ASH recommended that Health Net should consider paying the claim through its normal medical benefit regardless.

“I see an ND for all my primary care, including my annual well woman exam last October,” said Fox-Quamme. “Every insurer covers well women visits, but Health Net denied that claim because I had it done by a naturopathic doctor. The only reason they even considered reversing the denial was because a law firm submitted an appeal. It is a huge problem if I need a lawyer to access basic, covered benefits.”

To date, four other patients had their denials reversed after a law firm submitted an additional appeal. Eight months after Fox-Quamme’s November 4, 2014 medical visit, the in-network Health Net naturopathic physician who provided her medical services has yet to be reimbursed by Health Net or its subcontractor ASH.

Advocates have been working directly with federal agencies and state insurance commissioners for the last two years to implement and enforce the provider non-discrimination provision to little effect. Both providers and patients have filed complaints to the state insurance division as well as to the Department of Labor. The most common reply stated that their hands were tied in terms of enforcement without clear guidelines or clarification of the law.

“The impact of this discrimination is clear,” said OANP Board President Carrie Baldwin-Sayre, ND. “Patients face unnecessary barriers to covered medical services, and naturopathic physicians are being arbitrarily limited in providing routine and preventive medical care. Until we have an impact judgment ruling, insurance carriers will continue to skirt the law, and patients and practitioners will be forced to pay the price.”

The group hopes that the suit will ensure that all qualified providers are able to work to the full extent of their license to help Oregon meet the Triple Aim of better care, better outcomes, and lower cost. The class action seeks several remedies, including: (1) reimbursement to individuals who have been denied benefits under their Health Net health insurance plans; (2) repayment of profits retained by Health Net as a result of its discriminatory practices; (3) enforcement of non-discriminatory practices in the future; and, (4) a court order for Health Net and ASH that clarifies which of their practices are unlawfully discriminatory.

The discriminatory Health Net/ASH practices cited in the lawsuit allege that unlawful limitations are imposed on naturopathic physicians as compared to other medical practitioners who provide commensurate medical services. These practices include: an annual limit on the number of reimbursable visits to naturopathic physician; the requirement of a Medical Necessity Review form, that other providers are not required to provide; a $1,500 maximum reimbursable cap for the use of naturopathic medical services; a limitation on certain types of medical care performed by naturopathic physicians that are within their scope of practice including, but not limited to, the delivery of preventative services; and, reimbursing naturopathic doctors at up to 80% less than other providers for the same service rather than varying reimbursement rates based on objective quality or performance measures.

The Oregon Board of Naturopathic Medicine has licensed naturopathic physicians in Oregon since 1928 with a broad scope of practice that allows naturopathic doctors to practice as primary care providers, including providing all preventative services, prescribing pharmaceuticals, and ordering all tests necessary to diagnose and treat illness.

Health Net included naturopathic physician services to their benefits as early as 2003, but has consistently restricted the scope of practice of naturopathic doctors by capping the number of times a patient could see their ND, limiting the kind of conditions that NDs can treat, declining payment for preventative services done by NDs, and/or restricting access to labs or pharmaceuticals when ordered by the ND.

Plaintiffs believe this class action lawsuit will produce a much-needed judgment to clarify the ACA’s provider non-discrimination mandate for a variety of provider types in Oregon as well as nation-wide.

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