Health Plan Agrees To Improve Medical Referral Process

Attorney General Spitzer's office today announced an agreement with one of the nation's leading health plans to improve its referral and claim payment process for the services of medical specialists.

The agreement - the first of its kind in New York - resolves complaints from both consumers and medical professionals that Aetna/US Healthcare erroneously denied coverage for specialist care.

"The services of medical specialists are critical to quality health care," said Deputy Attorney General Dietrich Snell. "As part of this agreement, Aetna will implement measures that will help ensure that people's claims for specialist care will be paid when they have followed a health plan's referral rules."

Aetna has agreed to streamline its referral process, and provide both consumers and medical specialists with an opportunity to resubmit claims that may have been denied improperly.

The Attorney General's office originally received complaints from individual consumers through its Health Care Bureau Hotline, as well as from the Westchester Medical Society, and consumer advocacy organizations, including the Medicare Rights Center.

It was alleged that Aetna was denying coverage for specialist care despite valid referrals from physicians. The claims were for the services of specialists ranging from podiatrists and dermatologists to neurologists and orthopedic surgeons.

An examination of the consumer and provider complaints revealed a number of reasons why denials had occurred. In some cases, the primary care physician did not communicate the referral in a timely manner or did not process referral paperwork correctly. In other instances, however, Aetna failed to properly process referrals and specialists' claims.

Aetna denied intentionally disallowing valid referrals, but did acknowledge administrative problems and agree to make improvements in its referral and claim payment process.

Snell commended the company for working with his office to address the problems. He also praised the Westchester Medical Society for its help in identifying undue administrative burdens facing consumers and medical professionals.

Medical Society President Peter S. Liebert said, "The Westchester Medical Society and physicians throughout the state welcome this long overdue correction. We thank the Attorney General's office and Dr. Andrew Kleinman for pursuing this issue on behalf of all patients and health care professionals."

Under the terms of the agreement, health plan members and medical specialists have until April 30, 2001 to resubmit claims from 1999 or 2000 that were denied for lack of a referral. Specialists may request a list of claims denied for lack of a referral and they will have 60 days to resubmit any claims they believe were erroneously denied.

The Attorney General's office is examining utilization review and claim payment practices by health plans in New York. The goal of this effort is to help ensure that health plans are following the letter and spirit of the state's Managed Care Consumer Bill of Rights approved in 1998. Earlier, the office reached agreements with several health plans to reform policies covering emergency room visits. This is the first agreement covering specialist services.

Aetna/US Healthcare, based in New Hartford, CT, provides health, dental and group insurance coverage to more than 30 million Americans.

The Aetna case was handled by Assistant Attorneys General Troy Oeschner, Heather Hussar and Howard Gootkin.

Consumers and providers with questions or concerns about health care matters can call the Attorney General's Health Care Hotline at 1-800-771-7755.


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