Ron Wyden (D-Ore), the Ranking Member of the U.S. Senate Committee on Finance, and Patty Murray (D-Wash), the Ranking Member of the U.S. Senate Committee on Health, Education, Labor, and Pensions, have asked Aetna Inc. for information concerning the insurer's procedures for reviewing health insurance claims for critical medical treatment.
In a letter to Aetna's chairman and chief executive officer, Mark T. Bertolini, the senators cited the recent CNN story about a former medical director for Aetna who said in a deposition that he never looked at patients' records when deciding whether to approve or deny care, instead relying on nurses to review the records and make recommendations to him.
"This episode," the senators wrote, "raises broader questions about the adequacy of Aetna's claims review process, the steps the company takes when evaluating patients' medical histories, and its compliance with federal law."
The senators also suggested that Aetna's appeals process "may not have been in compliance with federal law." If Aetna did not provide its insured who was featured in the CNN story with a copy of its denial letter, it may have violated "safeguards put in place by the Affordable Care Act that require insurers offering group or individual plans" to allow enrollees to review their file, "a critical consumer protection when a patient appeals an adverse insurance decision."
Among other things, the senators asked Aetna to provide the following by close of business on March 20:
- A written description of Aetna's claims review process, including the specific responsibilities of medical directors, nurses, and chief medical officers, as well as any other company employees who are involved in such decisions.
- Supporting documents related to Aetna's medical claims determination process, including but not limited to those establishing the steps medical directors are expected to take during consideration of insurance claims and appeals.
- A description of the medical claims determination and patient appeal processes specific to Aetna's Medicare Advantage and Medicare Part D plans and a description of any differences, including any review required by medical directors, in such processes compared to other non-Medicare Aetna plans.
- The total number of medical claims reviewed by the former medical director featured in the CNN story and the number for which he made determinations, during his tenure as medical director, and how many were approved and how many were denied.
- The total number of medical directors employed by Aetna to review and evaluate medical insurance claims for each of the past five years, and the total number of such claims they have reviewed, noting how many were approved and how many were denied, for each of the past five years.
- A description of all duties and responsibilities of Aetna's medical directors, including corporate activities other than claims review, and the performance evaluation criteria and procedures for all such duties and responsibilities.
- Guidelines and training materials that demonstrate how medical directors should communicate and consult with the nurse examiners.
- Guidelines and training materials regarding how medical directors are expected to handle claims when they lack expertise about the condition.
- The process medical directors should use when the medical director lacks expertise with regard to a beneficiary's condition or treatment.
- How many claimant requests for denial letters Aetna refused in each of the years 2014-2017.
- Supporting documents related to Aetna's policies and procedures governing claimants' access to their insurance records.
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