Blue Shield in Iowa ... insuring its own interests

by Dr. Jeffrey Shay

One thing about winter in Iowa, there's plenty of time to think. We don't waste our lives having a good time like in some larger venues due to the state's unique double whammy: No one has much money, and if they did, where would they spend it? Farm equipment shows? Des Moines?

Blue Shield does well here, as it does in most other states...maybe more so. While looking over my insurance cases recently, I noticed that Blue Shield (in Iowa it's Wellmark) has about 90% of the non‑government business in my area, i.e., everything that isn't Medicare and Medicaid. In most states that spells Trouble ("with a capital 'T' that rhymes with 'P' and that stands for Pool," if you saw the movie).

With a hammer‑lock on the market, you might think that Wellmark might be uncompetitive and unfair. You might be right. A cursory look at Wellmark's chiropractic policies would reinforce that picture. Note that the practices discussed here are probably extinct in other states.

The first problem is its so‑called Workman's Compensation policy. Any claim involving what might be a sprain is red‑flagged, with the claim being pended for further information. After all, Blue Shield doesn't want to pay for injuries that involve automobile insurance and workman's compensation injuries or other group insurances.

The problem here is that almost any claim falls under this aegis. Each week up to a third of my claims will be held up. Worse, the patient often doesn't understand the letter and dumps it into File 13. Sometimes the letter doesn't even get sent (I have several good patients who claim the letters arrive only sporadically, if at all).

Also, they now consider headaches and general aches and pains as possible WC claims. When I asked why headaches would be considered WC claims, I was told: "We're not on trial here."

Even worse, sometimes the patient finally mails back the form only to have the next claim for the same condition blocked a month later for another WC letter. This has happened more than once.

These so‑called WC claims are applied to people who don't even have jobs. I had a patient who got a job working 10 hours per week at a convenience store, with all subsequent claims being held up for processing by a non‑existent insurance. I called Blue Shield and asked them what kind of insurance Kum‑N‑Go gives to weekend workers.

Even better, Blue Shield routinely blocks payment for claims involving children. I have had claims declared Workman's Comp involving children as young as two years old. It's not a mistake. Blue Shield employees admit that claims are often pended for toddlers, but state that they are not exempt from the rules and need to fill out the forms. After all, that's why God invented crayons.

It gets better. When I called Wellmark and complained, I told them that I had filled out Blank 10 on the HCFA 1500 form, indicating that there was no WC claim, auto accident, or other claim involved. Wellmark's answer: "We are not required to read that blank."

It's a win‑win‑solution for Wellmark. Payments on these claims are delayed anywhere between four weeks to four months, depending on the patient. Some are never paid. Even better, few people seem to blame Wellmark. I had some patients get mad at me about this, saying "Why did you tell them this was a WC claim?"

The bad news about being under contract with Wellmark is the low payment levels. Iowa Medicaid pays more for adjustments that Blue Shield does. Even better, no claims blocked for automobile or workman's compensation claims unless I inform Medicaid of such an eventuality. Many insurance companies play the second‑pay game...Wellmark makes it an art form.

So, with all this going on, where is the Iowa Chiropractic Society?

Good question. Where IS the Iowa Chiropractic Society?

I think it's in Ankeny, and they charge a lot of dues. But they haven't been too active on issues like this. Or maybe they have been but none of us know about it, due to a low level of effectiveness. The answer may lie in their ACA sympathies.

Several years ago, I wrote an article about insurance companies using reviewers from a chiropractic college to refuse claims. ICS took no action, and I later found out why. It seems that they were also doing work for ICS. One was used as a speaker at a district meeting two weeks after I complained about him doing reviews for State Farm while teaching at a local chiropractic college. At one point ICS even sent a doctor over to a meeting to threaten me with expulsion from the society if I revealed their part in the scam. One of the reviewers who was backed by ICS didn't even have an Iowa license.

Years later, things haven't changed much. ICS still bears scrutiny, as does its relationship with the insurance industry. Maybe things have changed, but it doesn't look like it from here. ICS did suggest that the reviewers change their stationery, thinking it would fool me into thinking they were working for someone else. It didn't work. It also didn't work in Chicago, because everyone knew who worked for Capone.

I've been reading some ACA stuff lately, regarding their failed legal actions against Medicare and Trigon. If you didn't know better, you might almost believe they won. For example, they ballyhoo their victory over the PTs in the Medicare action, but many Medicare Choice providers still give patients no choice for chiropractic care.

And the Trigon case? ACA claims that the action, while lost, has definitely modified Blue Shield's actions nationwide. In my state, we're going to be paid $1 more per adjustment, but I've noticed that examinations on established patients are almost all being rejected. I can appeal (which I have) but I am allowed no direct input into the claim. More on this in my next column.

ACA's claim that Trigon was a success is similar to calling the Titanic's maiden voyage a success, since many passengers wound up on land, one way or the other. ACA is still taking contributions for these actions, which is like setting up a fund for new deck chairs.

Another coincidence is that ICS is one of the few state chiropractic organizations to approve of the Mercy standards and other procedures used to bilk DCs in this state. I am no longer a member. They threatened to throw me out so often that being a non‑member seemed appealing. I do remember that ICS, while claiming non‑affiliation with any national association, had a special representative to the ACA. I don't seem to remember a representative to the World Chiropractic Alliance.

By the way, this stuff wouldn't happen with a single‑pay national health system. If nothing else, there should at least be a statewide WC system. This would eliminate the obligatory Wellmark questionnaire. It won't happen, of course, because such efficiency could cost the insurance industry millions.

News items

*** Two members of the Iowa Board of Regents have resigned due to complaints of conflict of interest. It seems that the board members (whose job it is to oversee activities at the state‑funded universities and their medical facilities) also had positions at Wellmark Blue Shield while talks were proceeding on new insurance contracts with Wellmark. In fact, one of them happened to be the CEO and chairman of Wellmark. Although the two had recused themselves from board actions regarding the contracts, there was at least the problem of appearance of a conflict.

Neither could be reached for comment.

*** The state legislature here has come up with a solution to keep young adults from leaving Iowa, with the border looking like the old Checkpoint Charlie in Berlin. They're considering canceling state taxes for anyone under 30 who hasn't found his way across the state line. Needless to say, the debate has been furious.

A better idea might be to create jobs here that don't involve Wal‑Mart, Kwik‑Stop or a hog lot. Being freed from state taxes doesn't mean much if you're already eligible for food stamps.

(Dr. Jeffrey Shay, a graduate of Palmer College of Chiropractic and the WCA's 1996 "Chiropractor of the Year," is the World Chiropractic Alliance Director of Insurance Relations. He welcomes comments or questions regarding any insurance‑related subject appearing in this column. Dr. Shay is available to speak to your state or local organization. Contact him at 1300 Cedar St., Muscatine, IA 52761, or the WCA offices, FAX 480‑732‑9313.)