News: Aetna fined half a million dollars for denying ED claims

The California Department of Managed Health Care (DMHC) has fined Aetna $500,000 for denying almost 93% of investigated emergency department (ED) claims. The fine is the result of Aetna wrongfully denying their members’ ED claims and not following the state of California’s healthcare laws that ensure enrollees have emergency service coverage. The only exceptions are if the payer can prove the procedure never took place or that the member did not require emergency care services and reasonably should have known their condition did not warrant an emergency room visit.

The DMHC review of Aetna’s emergency care services denials found that 93% of the claims sampled should not have been denied under California law, and that the payer’s ED denials template for HMOs did not align with the state’s standards.

This, however, was not Aetna’s first time being fined for wrongfully denied ED claims in California; in 2015 and 2016, the insurer was ordered by the DMHC to pay $135,000 for denied emergency claims. Because of the previous court case on the same issue, Aetna now faces a $500,000 fine.

Echoing these allegations, many respondents to the 2020 CDI Week Industry Survey said that most of their organization’s denied claims came from private payers. One of the most prevalent write-in responses sited Aetna as the payer mostly to blame.

Editor’s note: Click here to find the DMHC’s coverage of this fine. For more information about CDI’s role with denials management, click here. The November/December edition of the CDI Journal will be focused on denials management and appeals. If you have a story idea or advice to share, please email Associate Editor Carolyn Riel (criel@acdis.org) and Editor Linnea Archibald (larchibald@acdis.org).