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Dynamic Chiropractic – September 9, 2011, Vol. 29, Issue 19
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dynamicchiropractic.com >> Personal Injury / Legal

Aetna Coverage Gaps Revealed

Insurer failed to follow Connecticut equality law.

By Editorial Staff

Hartford, Conn.-headquartered Aetna, whose open-access HMO in Connecticut operates as Aetna Health, Inc., made a big mistake – whether accidental or intentional is subject to great speculation – when it partnered with American Specialty Health Networks and began providing chiropractic to plan members: It ignored Connecticut law, which requires that any and all services provided by a medical doctor and eligible for reimbursement be equally reimbursed when provided by a doctor of chiropractic pursuant to their scope of practice.

The "oversight," which dates back to July 1, when Aetna's chiropractic agreement with ASHN became effective, means that Aetna and ASHN will need to review all chiropractic claims submitted but rejected since that date. As of press time, it is unknown how many claims will need to be reprocessed or how much money will ultimately be paid out to properly reimburse DCs whose claims were unjustly denied.

"Aetna's prompt and fair response to this issue means providers will be paid for covered services and Aetna's enrollees will continue to receive the care to which they are entitled," said Connecticut Attorney General George Jepsen in announcing the action. "Everyone benefits from this cooperation." Jepsen began asking questions after receiving complaints about Aetna from participating DCs.

As one might expect, this isn't the first time Aetna has made the headlines with regard to inappropriate / unfair coverage activities. For example, in 2007, the New Jersey Department of Banking & Insurance (DOBI) fined Aetna Health nearly $9.5 million for refusing to provide fair reimbursement for certain services performed by out-of-network providers. Two years later, the Association of New Jersey Chiropractors filed a class-action suit against the insurer alleging that Aetna's postpayment audit procedures violated the federal Employee Retirement Income Security Act of 1974 (ERISA) and the Racketeer Influenced and Corrupt Organizations Act (RICO). The suit also questioned Aetna's clinical policy bulletins used for retroactive denial of service. Litigation is ongoing.

And in perhaps the highest-profile case outside of chiropractic circles, Aetna was dealt a $120 million blow in a civil suit filed after a California district attorney insured by Aetna died of stomach cancer. According to the suit, filed by the man's wife, Aetna refused to pay for her husband's treatments, even though care was authorized by Aetna doctors.

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