Chiropractor groups in New Jersey and New York filed a class-action suit against Aetna Inc. over alleged abusive practices, including pre- and post-payment auditing they say violates federal laws.

The New York Chiropractic Council and the Association of New Jersey Chiropractors accuse the national health insurer of  “abusive practices in using post-payment audits, with false allegations of fraud, to pressure providers to repay substantial sums that have previously properly been paid for providing services to Aetna subscribers,” according to a statement from the groups’ law firms, Pomerantz Haudek Grossman & Gross and Buttaci & Leardi.

Aetna’s post-payment audit process allegedly violates the Employee Retirement Income Security Act of 1974 (ERISA), in that its repayment demands are retroactive determinations that particular services are not covered under the terms of Aetna’s health care plans, but without any of the appeal or other protections otherwise available under ERISA for both self-funded and fully insured health care plans offered through private employers.

The chiropractors say both the post-payment audit process and the pre-payment claim review process employed by Aetna to “strong-arm chiropractors into unfavorable settlements” violate the Racketeer Influenced and Corrupt Organizations Act (RICO), the lawyers said in the statement.

In addition to challenging the process by which Aetna pursues and applies its audits, the chiropractors say the numerous clinical policy bulletins of Aetna are used to deny services retroactively without adequate basis or clinical support.

Cynthia Michener, a spokewoman for Aetna, told IFAwebnews.com that the insurer “takes seriously our obligations to our employer customers and members to identify health care fraud and seek payment from those who abuse the health care payment system.”

The plaintiffs want Aetna to be barred from continuing to use its audit and recovery procedures, to stop from enforcing clinical policies that are substantively baseless and to pay for alleged coerced payments to resolve or defend against Aetna’s unlawful overpayment actions in cases where they were denied reimbursement for validly provided healthcare services.

“The scourge of post-payment audits by health insurers has become all too familiar to chiropractors across the country,” said Dr. Sigmund Miller, executive director of the ANJC, said in a statement. “Indeed, insurance carriers continue to bombard chiropractors with refund requests demanding repayment of thousands upon thousands of dollars. Aetna, in particular, has been active in auditing and thereafter seeking recoupment from chiropractors.”

The ANJC and the NYCC are participating in the action in an associational capacity on behalf of their members. Four chiropractors, Donna Restivo and Christopher Foglia, both of New York, Todd Carnucci of New Jersey and Peter Manz of Ohio, as well as one surgeon, Leon Egozi of Florida are named as plaintiffs in the class action.

“These plaintiffs, all of whom have been egregiously harmed by Aetna’s improper practices, are standing up to represent the interests of their profession,” says D. Brian Hufford of Pomerantz Haudek. “We are seeking to add fairness into the process, while protecting providers whom Aetna is attacking for simply doing their jobs in providing medically necessary health care services to their patients.”

In the complaint, plaintiffs allege that, as a means to maximize its profits, Aetna is using its post-payment audit process to pressure providers by claiming that they have been overpaid in the past for services that are not deemed to be covered under its health care policies, including because they purportedly are experimental and investigational.

“Not only are Aetna’s policies invalid and contrary to acceptable medical procedures,” says Vincent N. Buttaci of Buttaci & Leardi, “but in making its demands Aetna fails to provide even minimal due process, which is required under ERISA before Aetna can make an adverse benefit determination.”

The complaint further alleges that, in making its recoupment demands, Aetna uses “statistical extrapolations” from its purported review of just a handful of claims, thereby issuing retrospective denials of numerous other non-reviewed services. In doing so, Aetna violates — and continues to violate — the legal rights of providers, and the patients they treat.