Aetna Denies ER Care – Fined by Department of Managed Health Care
Aetna denies ER claims incorrectly and is fined $500,000 by the California Department of Managed Health Care (DMHC). According to the DMHC, Aetna Health of California, Inc. (Aetna) incorrectly uses the national standard to deny paying ER claims. Aetna should instead be applying California’s broader standard for emergency room bills.
California requires health insurance plans to cover emergency room services. The only exceptions are when ER services are not required or when they never occurred. In 2019, the DMHC reviewed a sampling of Aetna ER claims. The DMHC found 93% of Aetna’s denied emergency room claims should have been approved. The issue was that Aetna’s denial template for HMOs followed national, not California standards.
This was not the first time the DMHC fined Aetna. The DMHC fined Aetna $135,000 in 2015 and 2016 for incorrectly denying ER claims. Aetna paid fines and trained its employees to better understand how to review California ER claims. The 2020 fine of $500,000 is larger than past fines because Aetna has repeatedly failed to correct this problem.
Our Cases Have Discovered Troubling Aetna Internal Review Processes in the Past
Unfortunately, and for a variety of reasons, health insurance companies deny legitimate claims. A few years ago, we uncovered Aetna’s troubling review process. In this process, medical directors didn’t review medical records prior to denying treatment. Our discovery led to national news. It also led to investigations into Aetna by the United States Senate, California Department of Managed Health Care, and the California Department of Insurance. In fact, even regulators from Colorado, Washington state and Connecticut initiated investigations.
If you are denied payment for emergency services, you should file a grievance with your health plan. Depending on your plan, a response should take no more than 30 days. You can also reach out to an attorney who specializes in health insurance law.
About the Law Offices of Scott Glovsky
The Law Offices of Scott Glovsky focuses on health insurance law. We have represented injured consumers and victims of wrongful business practices for more than the past two decades. Scott Glovsky is recognized as one California’s most experienced, compassionate, and trusted insurance law attorneys.