Ineffective healthcare navigation results in higher insurance costs for employers. Recent news about California regulators investigating Aetna’s medical coverage decisions illustrates this point.
Aetna Scandal: Insurance Medical Director Doesn’t Review Patient Chart Before Denying Coverage
This week, California’s insurance commissioner launched an investigation into Aetna after a former medical director for the insurer admitted under oath that he never looked at patients’ records when deciding whether to approve or deny care.
According to the article, the medical director based his decisions on information gathered from the medical record by nurses at Aetna. This is called chart abstraction and it’s a common practice in healthcare. Chart abstraction is a structured process for pulling important information from the medical record so it can be reviewed in an orderly fashion.
Why is this important? Because medical records are a mess. They are filled with pages and pages of boilerplate legal forms, lab results, EKG strips, daily physician notes, daily nurse notes, social worker notes, dialysis notes, operative notes and even outside pieces of information like notes from the emergency medical team on the ambulance.
Did the medical director read abstracted information from the chart? I don’t know, but it would be unrealistic to expect any type of medical reviewer—even from a hospital’s quality team—to read a “raw chart” that had not been abstracted.
In this case, the patient had been receiving expensive medication for years to treat a rare immune system disorder known as Common Variable Immune Deficiency. But in 2014, Aetna denied the patient’s monthly dose of immunoglobulin replacement therapy, saying his blood work was outdated.
Did the medical director make an error in requiring blood testing prior to authorizing further infusions? Maybe that was or was not a bad decision, I don’t know, but…
The article says the patient’s own doctor requested he have his blood work checked… which he refused to do. The patient’s doctor agreed with the Aetna request for a new blood test and the patient didn’t follow his doctor’s orders.
Eventually, the patient became so sick, his lung collapsed and he was admitted to the ICU.
Aside from the refusal to have the blood work done, the article says the patient had missed multiple scheduled infusions in the past.
What Employee Benefits Professionals Need to Know
This story illustrates potentially poor choices made by the:
- Medical director for not approving a treatment, resulting in an ICU admission
- Patient for refusing to have the blood work that his own doctor requested, resulting in an ICU admission
- Patient for not showing up for scheduled treatment infusions in the past
Ultimately, neither the insurance company or the patient pay for these “poor choices”—the employer does. If the patient is part of a self-funded insurance plan, his employer is underwriting these poor choices. If this patient is on a fully-insured plan that is fully-credible, his employer is paying for these poor choices in the form of higher premiums in the next year.
The capacity for “poor choices” in healthcare is almost infinite—by the carrier, patient AND provider—and ultimately the risk is borne by the employer. More specifically, this story is an example of healthcare and health insurance navigation gone bad.
Employee benefits professionals are responsible for developing risk management strategies for “poor choices.” These strategies need to include healthcare and health insurance navigation.
If employers are not actively involved in the healthcare decisions being made by their plan members, they have essentially written a blank check for “poor choices.”
This is about more than money. It’s literally about pain, suffering, emotional turmoil and family strife. I’ve written it before, employees are the lifeblood of an organization. Poor choices can be addressed… employers do it every day in other areas of their businesses. It can be done in healthcare and health insurance, as well.
To learn how Compass helps employee benefits professionals provide employees with healthcare navigation services that help employees make smarter healthcare decisions that lower healthcare costs and improve care. To learn more, visit www.compassphs.com/compass-navigator.