Tuesday, August 25, 2020
DMHC Orders Aetna to Stop Wrongfully Denying Payment for Emergency Medical Service
Department Fines Plan $500,000 for Repeated Violations
(Sacramento) – The California Department of Managed Health Care (DMHC) today ordered Aetna Health of California, Inc. (Aetna) to stop using the plan’s national standard to deny payment for emergency room claims. This practice has resulted in Aetna wrongfully denying members’ emergency room claims as the plan should be applying California’s broader standard to approve emergency room services.
The Department has also fined Aetna $500,000 for repeatedly failing to apply California law and failing to implement corrective actions to correct this problem. Aetna has repeatedly agreed to follow California’s standard for reimbursing emergency room claims but has continued to use its national standard, resulting in many wrongful denials of emergency room claims.
“The plan’s failure to follow California law for reimbursing emergency room claims is unacceptable,” said Acting DMHC Director Mary Watanabe. “This has resulted in Aetna wrongfully denying emergency room claims. Aetna must follow the state’s health care laws to ensure enrollees have access to the care they need.”
California law requires a health plan to pay for emergency medical services unless it is in possession of evidence to show that either the emergency medical services were never performed or the enrollee did not require emergency medical services and reasonably should have known that an emergency did not exist.
The Department has previously taken enforcement action against Aetna for improperly denying coverage for enrollees’ emergency medical services. Aetna entered into settlement agreements with the DMHC in 2015 and 2016 and paid $135,000 in fines. Aetna also agreed to Corrective Action Plans requiring training for employees handling claims for emergency services and reimbursement for emergency services based on the California standard.
Despite the enforcement actions taken against the plan to correct its deficiencies, the DMHC Help Center received four complaints in 2018 and 2019 showing that the plan had wrongfully denied emergency room claims based on the incorrect standard. The DMHC then conducted a medical survey of the plan’s operations and reviewed a sample of the plan’s denials of emergency medical services. In 2019, the Department’s final survey report concluded that 93 percent of the sampled claims were wrongfully denied. The Department also reviewed Aetna’s commercial emergency medical services denial template for HMOs and determined that the templates did not follow California law.
If a health plan denies payment for emergency services, the health plan enrollee should file a grievance with their health plan and include a copy of the bill. Their health plan will review the grievance and should ensure the plan is following the California standard. If the consumer does not agree with their health plan's response or if the plan takes more than 30 days to fix the problem, they can file a complaint with the DMHC Help Center at www.HealthHelp.ca.gov or 1-888-466-2219.
About DMHC:
The DMHC protects the health care rights of more than 26 million Californians and ensures a stable health care delivery system. The DMHC Help Center has assisted approximately 2.4 million Californians to resolve complaints and issues with their health plan. The DMHC Help Center provides assistance in all languages and all services are free. For more information visit www.HealthHelp.ca.gov or call 1-888-466-2219.