California launches probe into Aetna

[ajm184]

https://www.cnn.com/2018/02/11/health/aetna-california-investigation/index.html

 

Though the individual case may or may not be defensible, Aetna has managed to bring every single state and federal regulatory authority to examine all of their pre-authorization/claim denial practices into focus.

If I were a practicing physician, I would the revelations infuriating when someone who doesn't have the training and expertise make 'recommendations' and the physician a. not having the medical record and b. not have the expertise (via specialty) to make an informed decision.  This in turn translates to wasted time/resources to 'educate' or appeal to the insurance company.  Don't see a way the Feds are not going to hold up the Aetna/CVS merger until investigations are completed by the states, plus CVS would now get Aetna at a discount if they don't walk away entirely.

[pistolpete]

This is terribly sad. But we all knew it was happening.

[Zaphod]

pistolpete wrote:

This is terribly sad. But we all knew it was happening.

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Yeah, I couldnt believe they found all those doctors who were "shocked" thats the practice. I thought it was simply:

Claim made:

1. Deny

Appeal made:

1. Deny, with 'review'

Further appeal

1. Try your best to deny, obviously.

 

In the particular case above, dont think the patient has much standing except they will be liable for their obscene practices. Its not unreasonable to want labs more recent than 3 years. Typical patient that is very serious about responsibility except when its their own. Didnt seem to care about the doctor or doing any necessary preventative stuff until he got deathly ill. Thats a self made issue. Thats just what I got from the horses mouth, no further details, but sadly typical. Even with what I do, 95% of my post op care consists of trying to keep patients from hurting themselves and their results by either not following directions, over doing it, or not paying attention to what should be obvious things.

[LizOB]

Apparently it's at least somewhat effective when your peer-review is denied is to ask your "peer" for their full name with spelling, state of licence and licence number, and tell them it's so you can put it in the patient's chart as the person making this decision regarding their medical care. Haven't tried it myself yet though

[MrsIMDoc]

LizOB wrote:

Apparently it’s at least somewhat effective when your peer-review is denied is to ask your “peer” for their full name with spelling, state of licence and licence number, and tell them it’s so you can put it in the patient’s chart as the person making this decision regarding their medical care. Haven’t tried it myself yet though

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I have and it works.  I also add, "I am documenting here that you are denying this and any harm to come to this patient based on this denial will be your responsibility."

 

[ENT Doc]

I am Jack's complete lack of surprise.

[StarTrekDoc]

Denial is part of their process.  Peer-to-peer is a hurdle game;   we now ask to schedule a time for peer-2-peer doc-to-doc as often the 'peer' on the other side is an RN talking to our doc after 4 menus prompts and 15minutes of waiting.

So, now our referral clerk calls them to arrange a 10minute window for direct doc-to-doc review;  it's amazing that a second request for records review and resolution occurs with this 'hurdle game' that we put into place.   

[MPMD]

LizOB wrote:

Apparently it’s at least somewhat effective when your peer-review is denied is to ask your “peer” for their full name with spelling, state of licence and licence number, and tell them it’s so you can put it in the patient’s chart as the person making this decision regarding their medical care. Haven’t tried it myself yet though

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that is awesome.

not an issue in my field but i would do it if i could.

 

[CM]

LizOB wrote:

Apparently it’s at least somewhat effective when your peer-review is denied is to ask your “peer” for their full name with spelling, state of licence and licence number, and tell them it’s so you can put it in the patient’s chart as the person making this decision regarding their medical care. Haven’t tried it myself yet though

Click to expand...

I did this once about 18 years ago. I didn't ask for license, but asked for the full name and told the peer that I would write in the chart that I recommended "x" but that he denied coverage for "x." He immediately changed his mind and approved coverage.

[Hank]

It's worse in dentistry.  You routinely get some "maybe graduated high school, maybe dropped out" customer service rep in El Paso denying treatment or diagnosing the patient.  The language of the patient's insurance policy routinely re-defines black as white and up as down.  Evidence based medicine goes by the wayside.

I'm hard pressed to see how Dr. Iinuma keeps his medical license after this.

[wideopenspaces]

Count me as one of the shocked doctors. In outpatient psychiatry we don't get denials. Sometimes on new meds they have to try two older meds in the same class before insurance will cover, but that's it. This story is completely insane to me! I have to deal with disability insurance companies pretty regularly and always speak with a board certified psychiatrist. I would expect better from someone making actual treatment decisions.

[tex]

Not shocked that a for-profit company that makes profit by paying for as little healthcare as possible by charging as much as possible is seeking to do that as cheaply as possible.

[pulmdoc]

I'm only shocked that the case made it public, most insurance policies have binding arbitration with a confidentiality clause built in to prevent this sort of bad press.

I'm sadly not shocked at all that the medical reviewer knew nothing about the disease, although also admitting he didn't even look at the chart before denying coverage is a bit of a woofer. It is routine in my practice that peer to peer phone calls mainly consist of my educating the doc on the other end of the line about the standard of care and that yes, I have properly documented treatment failures before going to 5th line expensive medication. The whole goal of the process is to goad physicians into "self denial" by giving up along the way due to frustration.

[Zaphod]

pulmdoc wrote:

I’m only shocked that the case made it public, most insurance policies have binding arbitration with a confidentiality clause built in to prevent this sort of bad press.

I’m sadly not shocked at all that the medical reviewer knew nothing about the disease, although also admitting he didn’t even look at the chart before denying coverage is a bit of a woofer. It is routine in my practice that peer to peer phone calls mainly consist of my educating the doc on the other end of the line about the standard of care and that yes, I have properly documented treatment failures before going to 5th line expensive medication. The whole goal of the process is to goad physicians into “self denial” by giving up along the way due to frustration.

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Exactly, they hope you quit trying, that way they dont have to pay even legitimate claims.

I dont fault him for not looking at the chart in this particular or really any case, they have an algorithmic job, "are these boxes checked" "or not". This case wasnt checked and no further intervention necessary, makes perfect sense. Theyre arent paid to look at charts, theyre paid to deny claims. Follow the money. I know people think Im cynical, but seriously, this kind of thing is super obvious.

[Rando]

I'm not really shocked by this, and am not even convinced yet this is necessarily a bad thing.  My understanding is the director has people (nurses) that go through the charts and summarize the salient points, then he makes decisions based on those.  For a director to personally do the grunt work of going through many pages of charts would not be a wise use of his time.  For him to never personally review a chart does sound pretty bad though.