- Despite previous enforcement action, Aetna continued denying coverage for members' emergency services, California's Department of Managed Healthcare alleged this week in a cease and desist order filed against the insurer. Aetna now faces a $500,000 fine for repeatedly failing to correct the problem.
- The department launched an investigation after it received consumer complaints of ER denials in 2018 and 2019. The department found 93% of claims it sampled wrongfully denied ER coverage.
- Aetna said it is cooperating with the department and has "taken a number of steps to help ensure that we handle emergency room claims consistent with California's standard for determining whether an emergency medical condition exists."
The problem in California centers around Aetna applying a different standard for denying emergency room visits, one that is in conflict with state law.
In one instance, a 37-year-old woman was denied coverage in 2018 after going to the ER while experiencing "excruciating and debilitating" leg pain, fearful she had deep vein thrombosis based on prior medical history, according to the legal documents filed by the department. Aetna denied coverage "because her condition did not meet its national 'prudent layperson' standard."
However, in California, in this instance, Aetna would have to show that the enrollee reasonably should have known that an emergency did not exist as required by California law. But it failed to do so, according to the legal filings.
"California law requires a health plan to pay for emergency medical services unless it is in possession of evidence to show that either the emergency medical services were never performed or the enrollee did not require emergency medical services and reasonably should have known that an emergency did not exist," the department said in a release this week.
This is not the first time Aetna has tried to apply its national prudent layperson standard to its HMO enrollees in California, the department said.
Aetna entered into settlement agreements with the department in 2015 and 2016 and faced $135,000 in fines. It also previously agreed to corrective action plans to train employees on how to properly handle ER claims and reimbursement.
Aetna will now have to conduct a review of all its ER claims since Feb. 1, 2017, and overturn each denial unless it can prove the services were never performed or that the enrollee should have known an emergency did not exist. It also needs to submit a report detailing how it will comply with the cease and desist order.