February 13, 2018
This week, the California Department of Insurance (CDI) and the Department of Managed Health Care (DMHC) announced an investigation into Aetna Inc.’s coverage denials that appear to put profits before patients. The investigations were launched, in part, after a former Aetna medical director admitted he never looked at patients’ records when deciding whether to approve or deny health care. Denying coverage without a physician ever reviewing medical records is a potential violation of law.
“California physicians are increasingly concerned with the growing trend of for-profit insurance companies adopting policies that restrict access to care while their profits soar,” said California Medical Association (CMA) President Theodore M. Mazer, M.D. “We applaud the CDI and DMHC for investigating whether health insurers are using their market power to unjustly and illegally deny medically necessary care recommended by the treating physician. The burden of proof should rest with insurers to prove – with an expert medical and thorough review – why treatment should be stopped, not on treating physicians or patients.”
What’s more, nearly 60 percent of the total Independent Medical Reviews (IMR) filed against Aetna with DMHC in 2016 were overturned or reversed. This follows a growing trend of the regulator denying or reversing health plan decisions by almost 20 percent over the last three years (51 percent in 2014 to 69 percent in 2016).
“The growth of IMR reversals is troubling and suggests that for-profit insurance companies are inappropriately denying care without evaluating the specific clinical issues,” said Dr. Mazer. “For-profit insurance companies should not be allowed to set aside the decision of a treating physician without demonstrating that the treatment in question conflicts with scientific evidence, professional standards or expert opinion.”
CDI Commissioner Dave Jones has asked Californians who believe they may have been adversely impacted by Aetna’s decisions to contact the agency: www.insurance.ca.gov.
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The California Medical Association represents the state’s physicians with more than 43,000 members in all modes of practice and specialties. CMA is dedicated to the health of all patients in California. For more information, please visit Facebook, Twitter, LinkedIn and Instagram.