DMHC Fines Aetna $125K For Denials

Aetna Health of California was fined $125,000 last week by the Department of Managed Health Care for systematically denying payments for emergency care.

According to state records, Aetna systematically misapplied state regulations in deciding to deny payments for care. Specifically, Aetna erroneously concluded in many cases that the patient who received emergency care should have reasonably known that an emergency did not exist. 

Under state law, the burden is on Aetna to prove the patient's state of mind regarding whether they needed emergency care prior to denying denying payment.

But according to the DMHC, “(Aetna) in some cases, denied claims without even having the complete emergency room records, including the critical triage notes which explain why the enrollee reported to the emergency facility.”

The DMHC said it was first notified of the issue through enrollee grievances it received beginning in 2010. 

Aetna agreed to an informal corrective action plan, but the agency continued to receive complaints from consumers.

Altogether, Aetna incorrect denied payments for emergency services for eight of its enrollees between 2011 and 2013. The sums that were in dispute were not disclosed.

The penalty is the 117th levied against Aetna by the DMHC since 2001. The fine is the fourth largest against the health plan. It had previously been fined $200,000 in 2014 and $150,000 on two other occasions for failures to handle claims correctly and include interest on those claims that were paid late.