California has launched an investigation into Aetna. Here’s the problem:
- Insurers have medical doctors (“medical director” is the job title) on staff whose job it is to determine whether a claim is for treatment that was medically necessary and is covered under the terms of the insurance.
- In a court case, a medical director for Aetna testified that he never looked at patient records in determining whether a procedure should be covered or not. He simply read notes prepared by nurses on the insurer’s staff about the case.
That raises several questions:
- If the doctor is simply relying on the nurses’ judgment, why is the doctor there?
- If the nurses are competent to make the decision, why is a doctor required to rubberstamp it?
- If the nurse’s aren’t competent (and the one’s have had occasion to speak with at insurers aren’t the beset), how does this process serve the patient?
- Does the process have a bias toward delaying legitimate claims and boosting insurer profits?
- How many other insurers are following the same defective practice?
The implication is that consumers have to be more aggressive in enforcing their rights against insurers. Don’t trust the insurance company, and don’t hesitate to file an appeal and get a lawyer if the insurer makes a decision that seems unreasonable.
Full disclosure: I’m not fond of Aetna, period. I used to sell coverage for them (small group) in NJ until they decided they didn’t want to sell it and abandoned the market. Before that, their health insurance pricing was the highest in New Jersey among all ACA providers.