Aetna U.S. Healthcare's plan to create an external review policy for denied coverage decisions is aimed at bolstering the managed-care giant's reputation with patients and providers alike.
Blue Bell, Pa.-based Aetna's announcement comes on the heels of a provider exodus from the plan, particularly in Ohio and Texas.
Other managed-care companies have external review policies, but Aetna is the first national company to implement one for all its products and enrollees. It plans to have external review arrangements in place for all HMO and point-of-service enrollees by early summer. Physicians also will be able to appeal coverage denials on behalf of patients. Aetna plans to contract with organizations that specialize in external reviews.
Under the new policy, enrollees who have exhausted Aetna's internal appeals procedures may go to an external review organization, which will be made up of independent physicians. The panel will make decisions within 60 days, or sooner in life-threatening cases. Aetna will pay for the independent reviews.
Several of the 30 states in which Aetna does business already have state-mandated external review committees. In those states, the existing committees will hear the complaints of enrollees.
According to Aetna spokeswoman Jill Griffiths, the external review committee in New Jersey last year heard only eight appeals from Aetna enrollees, and seven were upheld for the plan.
"I think physicians will be pleased to know we're willing to be held accountable for our decisions," she says, adding the policy is just "one of a number of initiatives we've rolled out that will go a long way in enhancing our relationships with physicians."
Russell Dean, executive director of the Academy of Medicine of Cincinnati, greets the announcement as a small step in the right direction. Aetna's relations with providers in Ohio have been strained for months, and a number of Cincinnati-area providers have left the network, citing restrictive contracts and low reimbursement.
"It sounds like Aetna is trying to inject some impartiality into the process," Dean says. "If that's the light, however small it is, at the end of the tunnel, and a physician feels strongly on behalf of the patient that an improper decision was made, then I suspect some will go to whatever lengths they have to. That's why I think it's a small step in the right direction."
Last month, Karen Ignagni, president of the American Association of Health Plans, told the Wall Street Journal that the organization is considering a broad external review policy.