Official Grievance Letter (PDF, 25 pages)

August 30th, 2018

Appeals & Grievance Department
Blue Shield of California
P.O Box 927
Woodland Hills, CA 91365-9856

Dear Blue Shield of California:

The undersigned California and national acupuncture associations are writing to express concerns about recent directives by Blue Shield of California (BSC). These directives are having profoundly detrimental effects on the ability of our practitioners to practice, and on the opportunity for patients to receive care. We represent the largest licensed group of practitioners offering acupuncture, which is one of the most widely recognized, non-pharmacologic pain management strategies discussed in current times, especially in relation to the opioid epidemic. We feel that it is of immediate importance that BSC rescind the destructive policies which stand in the way of patients receiving acupuncture care, and which fuel the opioid crisis rather than help to solve it.

KEY POLICY CONCERN:
The key policy of concern is Policy # 0055: Acupuncture When Billed with Evaluation and Management. This policy states, “[it] will be effective for claims processed on and after [January 1, 2018]. E&M services performed by a physician or other health care professional and billed with Acupuncture services will not be eligible for reimbursement. This policy followed another announcement: Adjustments to Fee Allowance Schedule for Acupuncturists, effective December, 1, 2017. This policy downgraded or eliminated the reimbursement for all E/M codes for acupuncture and acupuncture treatment related services. This policy change was sent on Sept. 21, 2017. A copy of that letter is attached hereto. “Attachment A1 and A2.”

These policies highlight a failure on the part of BSC to revise payment coverage policies which would encourage healthcare providers to prioritize non-opioid pain management treatments. The recent downgrading of E/M Codes for acupuncture services has dramatically gone against the National Association of Attorney General’s recommendation, being emblematic of policy that forces providers Out-of-Network with BSC due to insurance reimbursements that are insufficient to cover the cost of providing care for patients. “Attachment B.” The non-allowance of E&M codes in conjunction with acupuncture codes is arbitrary and does not reflect the care that may commonly be provided in clinics.

For more than 30 years, CSOMA and its members have served as a consistent voice of the profession. During that same time, dozens of different associations, many of which are language-specific to their particular constituency, have been created in an effort to support the scale and diversity of the acupuncture profession in California.

BACKGROUND:
On September 18th, 2017 the National Association of Attorneys General (NAAG) sent a correspondence to Marilyn Tavenner, President and CEO of America’s Health Insurance Plans regarding the Prescription Opioid Epidemic, specifically recommending, “that AHIP take proactive steps in revising their payment and coverage policies to encourage healthcare providers to prioritize non-opioid pain management options over opioids. A copy of that letter is attached hereto signed by California’s Attorney General, Xavier Becerra. Shortly thereafter, BSC sent a correspondence dated September 21, 2017 dramatically reducing reimbursement rates for all E/M codes for acupuncture services.

The AG letter was quite specific in its understanding of the opioid epidemic and included, “We have witnessed firsthand the devastation that the opioid epidemic has wrought on our States in terms of lives lost and the costs it has imposed on our healthcare system and the broader economy.” They then present the importance of non-opioid care for chronic pain, “When patients seek treatment for any of the myriad conditions that cause chronic pain, doctors should be encouraged to explore and prescribe effective non-opioid alternatives, ranging from non-opioid medications (such as NSAIDs) to physical therapy, acupuncture, massage, and chiropractic care.”

The NAAG then presented the most sobering argument related to insurance company social responsibility for such non-opioid alternatives, “Insurance companies can play an important role in reducing opioid prescriptions and making it easier for patients to access other forms of pain management treatment. Indeed, simply asking providers to consider providing alternative treatments is impractical in the absence of a supporting incentive structure. All else being equal, providers will often favor those treatment options that are most likely to be compensated, either by the government, an insurance provider, or a patient paying out-of-pocket. Insurance companies thus are in a position to make a very positive impact in the way that providers treat patients with chronic pain.”

They conclude with a call to action for our nationwide insurance providers highlighting, “Adopting an incentive structure that rewards the use of non-opioid pain management techniques for chronic, non-cancer pain will have many benefits. Given the correlation between increased supply and opioid abuse, the societal benefits speak for themselves. Beyond that, incentivizing opioid alternatives promotes evidence-based techniques that are more effective at mitigating this type of pain, and, over the long-run, more cost-efficient. Thus, adopting such policies benefits patients, society, and insurers alike.”

Not only the NAAG is making a strong case to insurance providers to increase the opportunity for their insureds to be treated for the myriad conditions that cause chronic pain, and with a citation that such treatments are more cost effective. This is further supported by the Consortium Task Force White Paper, “Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care” as well as many other published studies and journal articles related to acupuncture treatment in the opioid epidemic. “Attachment C.”

The Dec. 1, 2017 rate reductions have already significantly hindered the ability of our providers to offer care, and are having a destructive impact on the abilities of your insureds’ to receive needed treatments. These policies affect numerous acupuncture specialists and a significant number of patients. Our organizations are deeply concerned with BSC’s trend in policy regarding acupuncture coverage, and hence its trend to work against the public health community and Attorney’s General in recommendations to meaningfully support non-pharmacologic pain solutions. Our nation is in an opioid crisis, and BSC is taking deliberate steps to make that crisis worse. These policies create obstacles for Licensed Acupuncturists to practice medicine in California and other states in which they are licensed, and to be paid commensurate with the services they provide.

Given that the combination of these policies are already affecting numerous Licensed Acupuncturists and countless patients with varying clinical conditions that can lead to chronic pain, we urge Blue Shield of California to rescind these policies and consider engaging the provider community in a concerted, serious dialogue on how to best deliver “alternative” medical care (which is no longer alternative) in a cost effective and efficient manner.These issues are important priorities for our respective organizations, and we will continue to work collectively to accomplish a mutually agreeable solution that addresses our concerns. We, thereby, request a formal response to our concerns within 30 days of receipt of this letter. We are certain BSC did not intend to be the stand-out company working against national opioid crisis efforts, and together we can certainly find a way to make it instead a leader in solutions.

We look forward to working with you on these issues. Please do not hesitate to contact Tiffany Tuftee, President, CSOMA (president@csomaonline.org); 831-515-6049), or Ra Adcock, Executive Director, CSOMA(ra@csomaonline.org, 1800-477-4564) with any questions or concerns.

Respectfully yours,

Tiffany Tuftee
CSOMA President
president@csomaonline.org

Ra Adcock
CSOMA Executive Director
ra@csomaonline.org

The California State Oriental Medical Association

CC: California Governor, Governor Jerry Brown California Attorney General, Xavier Becerra California Insurance Commissioner, Dave Jones Department of Managed Care