Feb. 12, 2018 – Revelations Sunday by CNN that Aetna’s former Southern California medical director admitted under oath that he never looked at patient records when deciding whether to approve or deny care highlights a widespread abuse in the insurance industry that can have catastrophic consequences for patients, said the California Nurses Association/National Nurses United today.

The case, which only came to light following litigation about a denial of care, is hardly an isolated incident, notes CNA.

Just last week CNA reported new data its researchers had uncovered that documented that 60 percent to 80 percent of health insurance denials are reversed by independent medical review by the California Department of Managed Health Care.

“California can end this behavior and protect our families and neighbors by changing to a system based on patient need, as proposed by SB 562 which would guarantee coverage for everyone and eliminate premiums, deductibles, and insurance denials. The Assembly should act on the bill now,” said CNA Co-President Deborah Burger, RN.

“Denials of care are increasingly common, with insurers creating a variety of pretexts which all amount to nothing more than the insurance company doesn’t want to pay for needed care, regardless of how much suffering it causes a patient,” said Burger.

In 2016 alone, the most recent year for which there is data

·      60 percent of cases insurers denied as “not medically necessary” were either overturned by CDMCH independent medical review or ultimately reversed by the insurer.

·      80 percent of cases insurers denied as “experimental” or “investigational” were overturned or reversed by the insurer.

·      52 percent of cases where insurers refused to authorize payment for emergency or urgent care provided to a patient were overturned or reversed by the insurer.

Aetna is a prime example, says CNA. Of the cases that went to independent medical review in 2016, Aetna denials were upheld only 40 percent of the time.

“Everything about the case reported by CNN report is a reminder why we need SB 562 – from the admission that Aetna’s former medical director to the case itself, in which a young patient was denied critical care, said Burger. http://www.cnn.com/2018/02/11/health/aetna-california-investigation/index.html

For years, California insurers were required to report total numbers of claims denials, until CNA researchers uncovered that data and published findings that from 2002 through 2010, the state’s largest insurance companies denied 26 percent of all claims. The state stopped publishing that data after it was widely reported in the media.

But while that data is no longer publicly reported, the independent medical review data is. The process is triggered after the insurer has denied a specific medical treatment, diagnostic test, or referral to a specialist, or a certain prescription medication.

In most cases, members must first file a grievance with their insurer and allow 30 days for it to be processed before filing for an independent medical review. Yet, grievance systems are rife with abuse, says CNA, such as failure to establish a grievance system, failure to respond to patients in a timely manner, and similar violations. For the largest insurers, those with more than 400,000 enrollees, 64 percent of violations with monetary penalties were related to the insurer’s improper grievance process.

“If anything, claims denials are actually under reported,” notes Burger. “It’s deliberately an arduous, burdensome process, buried in insurance fine print so that many patients are either unaware that they can appeal a care denial, or get so frustrated by the lengthy delay and bureaucracy that they stop fighting. That’s the disgraceful game that insurance companies play with people’s lives,” Burger said.