Aetna Adds Independent External Review Option to Individual Health Plans Nationwide
Effort designed to give members enhanced peace of mind, improve transparency
Aetna (NYSE: AET) announced today that, in keeping with its goal to deliver best-in-class consumer service and transparency, it has added an independent external review feature to its individual health plans. This process will allow Aetna members who face policy rescission to obtain, at no cost to them, an independent third-party review of Aetna’s decision, which will be binding on Aetna. The external review will be conducted by medical professionals from Boston-based MCMC LLC, a leading national provider of independent medical reviews with more than 20 years experience and more than one million reviews performed overall.
Policy rescission is the cancellation of an insurance policy, typically due to insurance fraud. Aetna has an exceptionally low rate of rescissions at less than 0.03 percent of all individual policies issued throughout its history in the individual marketplace. The company also already has a thorough internal review and appeal feature for members whose policies are being considered for rescission.
“This issue has generated much public attention for our industry, and we want to address it head on,” said Ronald A. Williams, Aetna chairman and chief executive officer. "At Aetna, we believe that the rescission process is a critical part of our efforts to combat fraud and misrepresentation to help keep costs more affordable for our customers. That said, we want to go the extra mile when it comes to the tough decision of rescinding the few policies we must and provide our members with an external review option in addition to our already existing internal review option.
“This nationwide independent review process should give consumers enhanced peace of mind that they will always be treated fairly and have access to a process independent of Aetna - it’s simply a matter of doing the right thing,” he added.
The majority of Aetna’s limited policy rescissions are due to insurance fraud, in which an individual obtains a policy under false pretense, makes an initial premium payment, immediately receives a medical procedure and then allows the policy to lapse.
Aetna has in place an extensive notification and appeals process to alert members if a rescission is being considered and, most importantly, to give members an opportunity to provide more information to factor into the decision process. The company sends out up to four separate letters providing the member with an opportunity to submit additional information. If a policy is rescinded, Aetna offers an internal appeals process in which a panel of medical underwriters and a medical director who were not involved in the original rescission decision review all available information.
Effective September 22, 2008, Aetna will supplement its current procedures by offering members an external review of a rescission to be conducted by an independent panel arranged by MCMC LLC, a company that also performs similar services for Aetna members on claims issues. MCMC will arrange for a panel of three medical professionals based on the specific needs of a particular case. The reviewers will re-examine all information used by Aetna in its decision process, including the medical records, timelines, other materials submitted by the member or the treating physician, and all relevant and appropriate medical literature. MCMC also will have the ability to interact directly with the member to gather further information as needed. Upon completion of the review, the reviewers will provide a “Rescission Review Report” directly to the member with a copy to Aetna. There will be no contact between Aetna and the reviewers at any time or with MCMC itself until the report has been independently mailed to the member.
Aetna is one of the nation’s leading diversified health care benefits companies, serving approximately 37.3 million people with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional and consumer-directed health insurance products and related services, including medical, pharmacy, dental, behavioral health, group life and disability plans, and medical management capabilities and health care management services for Medicaid plans. Our customers include employer groups, individuals, college students, part-time and hourly workers, health plans, governmental units, government-sponsored plans, labor groups and expatriates. www.aetna.com.
MCMC LLC (MCMC) is a national provider of independent medical reviews, examinations and related services. MCMC’s national reviewer panel consists of actively practicing, board certified physicians and allied health professionals covering all ABMS specialties. Last year MCMC performed in excess of 40,000 independent medical reviews for over 300 diverse clients.
With over 20 years of expertise, MCMC offers a variety of independent review programs and services. MCMC assists TPAs, self-funded plans, group health insurers, managed care organizations, and state mandated programs to better manage their utilization and case management challenges by assessing, improving and assuring the delivery of quality health care. For additional information pertaining to MCMC’s independent medical review program, please direct your inquiry to RescissionReviewProgram@MCMCllc.com.
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