If you had a bad experience with improperly denied claims or medical procedures by your insurance company, you are not alone. Insurers often dodge paying claims using terms such as not medically necessary or investigational. If that insurance carrier was Aetna, the problem may be a cultural problem from the executive suites down.
There are rules and regulations for how an insurance company behaves in each state. Unfortunately, not all insurers follow them and worse, many insurers have perfected the art of creating the proverbial “fly in the ointment”. They will use procedural mechanisms such as appeals and secondary appeals you must use to finally get them to cover medically appropriate care for your problem.
Insurance appeals are time consuming and have different levels that you can go through. Insurance companies know that people are busy and often will let things go. This is by the way how they increase profits and deny many appropriate tests and doctor visits. In doctors offices around the country, additional people are often hired to file these appeals to get your care covered and to reverse inappropriate claim denials.
Something is definitely wrong when a former Aetna Medical Director admits under oath that they would deny care without ever reviewing medical records as was recently reported recently by CNN.
This was discovered during a lawsuit brought against Aetna for medically appropriate care. Is there a cultural problem with Aetna?
If you ask your chiropractor or physical therapist about Aetna’s new NIA Magellan program which denies care and ties up healthcare providers with paperwork and phone calls using a system that is designed to be difficult for your provider to administrate and restrictive with the care they allow. This system is filled with flies in the ointment. Was this by accident or by design. Every state that has this new program is having problems with Aetna denials, procedures and the patients are not happy either.
After reading this article, you may begin to realize that there may be a huge cultural problem with one of the countries largest insurance carriers. Better yet, you may feel empowered to file an appeal when your care is denied inappropriately.
Check out this article recently published in Forbes.
Former Aetna Medical Director Admits To Never Reviewing Medical Records Before Denying Care
Robert Glatter, MD
Is this the exception or the rule?
In an eye-opening exclusive reported by CNN, it was revealed that former Aetna Medical Director, Dr. Jay Ken Iinuma, admitted under oath that “he never looked at patients’ records when deciding whether to approve or deny care.”
This admission was made during a deposition in a lawsuit brought against Aetna by Gillen Washington, a 23 year old with common variable immune deficiency (CVID) who was denied coverage for an infusion of intravenous immunoglobulin (IVIG) four years ago.
California’s insurance commissioner, Dave Jones, is now looking into Aetna’s relevant protocols.
In his deposition, Iinuma, as reported by CNN, “said he was following Aetna’s training, in which nurses reviewed records and made recommendations to him.”