The insurer’s coverage practices will be examined by the two different state departments.
Two California health insurance regulators have stated their intentions to investigate Aetna’s coverage decision processes. This examination of the insurer is a result of a lawsuit filed by a Californian man.
The man filed the lawsuit against the country’s third largest insurance company, alleging improper care denial.
The two California health insurance regulators will conduct the investigation in order to help determine whether or not Aetna’s decision processes are acceptable. The opening arguments in the case were made on Wednesday, February 14, 2018.
The Department of Managed Health Care is the first of the two regulators. It is responsible for regulating most of the health plans sold in California. It stated that it would be conducting an investigation into Aetna following the initial report of the case by CNN. That report indicated that one of Aetna’s medical directors had testified in one of the lawsuit’s depositions, saying that the defendant’s patient records were not consulted before the decision to deny care was made.
The California health insurance regulators are concerned that proper procedures are not being followed.
Instead of looking into the patient’s file himself, the medical director stated that he relied on the information provided to him by nurses who had reviewed the records themselves. He explained that Aetna had trained him to use that process in order to make his decisions regarding coverage for care.
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Upon hearing that report from CNN, the Department of Managed Health Care made the decision to look into the standard practices at the insurance company.
CNN had already reported California Insurance Commissioner Dave Jones’s office’s intentions to conduct their own investigation into Aetna’s health insurance practices. That statement was confirmed once again on Monday.
“If a health insurer is making decisions to deny coverage without a physician ever reviewing medical records, that is a significant concern and could be a violation of the law,” said Jones.
The scope of the investigations by the California health insurance regulators has yet to be determined as it is not yet known the breadth of the review issues are among patient claims by non-physicians within the company or even the industry as a whole.