The California Chiropractic Assn (CalChiro) Files Suit in Superior Court
San Francisco, CA – August 31, 2018 – The California Chiropractic Assn (CalChiro) filed suit here in San Francisco Superior Court, alleging among other complaints, One Call Medical, Inc. d/b/a One Call Care Management (OCM) and its subsidiary, Align Networks (Align) have violated California’s unfair competition law (UCL) as broadly defined in Business and Professions Code Section 17200 (Case No. CGC-18-569362).
The suit alleges that CalChiro and its members who are not contracted with Align have suffered injury and lost money or property as the result of numerous unlawful, unfair, and deceptive or fraudulent business acts and practices engaged in by OCM and Align. (To review the suit, click here.)
OCM and Align are accused of operating as unlicensed ‘middlemen’ between Workers’ Compensation payers and injured workers and their chiropractic providers. The allegations filed in Superior Court include:
- Neither OCM nor Align Networks is certified as a Claims Administrator under the Labor Code. CalChiro alleges that by managing the provision of chiropractic services and paying the claims submitted by chiropractors for therapy provided to injured workers on behalf of self-insured employers, that OCM and Align violate Labor Code § 3702.1 which requires only an insurer authorized to transact workers’ compensation insurance in California, or a third party administrator with a certificate of consent to administer self-insured employers’ workers’ compensation claims, can act as a Claims Administrator for self-insured employers.
- Defendants allegedly contract with chiropractic health care professionals under the guise that those who accept the lowest payment receive the most referrals.
- Defendants are alleged to then approach other chiropractors in the same geographic area demanding a contract at a yet steeper discount, making clear to those who do not buckle under to pressure to contract at the deeper discount, that they will receive referrals only when Align cannot refer to a contracted provider at a lower rate.
- Defendants’ payor clients do not directly pay health care professionals’ claims. Rather, OCM pays these claims and pockets whatever difference there is between what OCM is paid by payors and what OCM pays these medical professionals, creating a direct financial incentive to make referrals to the providers who have acquiesced to the deepest discounts. Thus, the larger the discount OCM obtains from contracted health care professionals, the greater the amount of compensation OCM retains from the employer or insurer who ultimately pays for the treatment services provided to injured workers.
- Under this scheme, defendants are alleged to engage in a uniform practice of soliciting and receiving improper payments for the referral of healthcare services and managing services provided to injured workers in California in violation of Labor Code § 3215, which prohibits offering or accepting any kind of compensation or inducement in exchange for referrals, in both its relationships with its workers’ compensation insurers, self-insured employers and third-party administrators and in its relationships with its contracted health care professionals.
- Align is also alleged to hold itself out as a medical provider because injured workers searching for a convenient chiropractor do not have access to the names of the licensed medical providers but are required to call the Align Networks phone number listed in the directory, at which point they are referred to a chiropractor by the Align Networks staff. These referrals are based on contracted rates rather than quality of care or patient choice. It is possible that this referral mechanism may endanger the certification of any Medical Provider Network (MPN) which contracts with Align for chiropractic care.
- Defendants’ claims handling and payment activities further violate the entire system governing the electronic handling and payment of bills for workers’ compensation medical treatment. Defendants’ alleged failure to accept electronic claims, acknowledge their receipt electronically upon submission, process and pay those claims expeditiously at no additional cost to the chiropractors, provide prompt, clear explanations of review for any claim contest or denial, and abide by the legally mandated internal and external billing dispute mechanisms violates Labor Code §§ 4603.2, 4603.4 and 4603.6 and their implementing regulations, 8 C.C.R. §§ 9792.5.1, et seq.
- As a result of Defendants’ alleged scheme, Defendants’ clients may have no idea of the magnitude of the discounts Defendants offer or impose, or how little Defendants are actually paying for the treatment services provided to injured workers and are reasonably likely be misled into believing that the treating providers are receiving fair compensation and that these clients’ injured employees are receiving optimal treatment for their injuries. They are also likely unaware of the material fact that Defendants are illegally demanding unreasonably large discounts as an inducement for the referral of these patients and misled into believing Defendants can lawfully conduct business in this State and have the required authorizations to do so, when that may well not be the case.
“CalChiro is confident we will prevail in this lawsuit.” said Dr. Danny Gambino, President. ”It’s essential that we stand up to those entities harming the chiropractic profession, and we are currently focused on OCM.”
About California Chiropractic Association
Established in 1928, CalChiro is a not-for-profit organization supporting thousands of doctors of chiropractic and students across California. Visit www.calchiro.org; call 916.648.2727. Social Media: Facebook, Twitter, Instagram, YouTube.