Aetna fined after denying 93% of ER claims in California

Insurers have come under scrutiny in the past for policies rejecting claims for visits to the emergency room that they deem unnecessary. The latest to find itself in hot water? Aetna, which has been fined $500,000 by California’s Department of Managed Health Care after a sampling of claims from 2019 found it had denied 93% that it deemed unnecessary.

“The plan’s failure to follow California law for reimbursing emergency room claims is unacceptable,” said acting DMHC Director Mary Watanabe said in a press release. “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.”

Related: What consumers need to know about appealing claim denials

While such policies seem like a prudent way to deal with consumers who run to the ER with symptoms of a common cold, the reality is that it’s hard to draw a clear line in the sand. California law requires all services to be covered unless the patient “reasonably should have known that an emergency did not exist.”

Aetna was also fined in 2015 and 2016 for its coverage denials and agreed to a corrective action plan. Still, according to the DHMC, the insurer’s standards for emergency room denials and its templates did not follow California law, following its own national standard instead.

While California may have stricter policies for emergency room claim denials, similar policy issues have drawn criticism nationwide in recent years. As noted by Health Payer Intelligence, in 2018, Anthem Blue Cross Blue Shield of Georgia drew outrage with its policy that would retroactively deny claims if the patient’s ultimate diagnosis was not considered an emergency.

Read more: 

• Aetna under investigation over care denials
• New York law would bar insurance denials for ‘urgent and medically necessary’ care
• Anthem faces legal challenges over ER, medical imaging policies