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Aetna Scandal Isn't Unique

Updated: Jul 2, 2019



Remember those infamous robo signings of mortgage applications that almost sent us into the hell of a Depression? Well, we have another twist on that one now. This time it's healthcare coverage and it's even worse than you can imagine. One young woman was denied brain surgery.

The media was rocked when a former medical director of Aetna admitted that he never read the medical reports of persons seeking reimbursement for medical claims; he just made a decision without any information. How can anyone, in any kind of screwed-up world, do that to people who thought they had coverage and paid their premiums? Ah, my friends, all in the interest of, as JFK's father used to say, filthy lucre.

But Aetna isn't the only place you'll find such unethical, criminal behavior. It just hasn't been uncovered yet. Three more states (Colorado, Washington and Connecticut) in

addition to California, are now involved in the Aetna investigation. Who knows where it may lead and, if there are whistleblowers out there, I sure hope they will blow their whistles on other companies that are acting similarly.

A few years ago, when I was working as a medical consultant for an agency that made disability determinations, I received a curious phone call from a reporter in California. The newspaper for which he worked was one I knew had a good reputation for reporting and longform journalism, so I listened to what he was researching.

Seems a physician, contracted by a California agency to make determinations on disability applications for benefits, was receiving $300K in fees for his yearly efforts. How could that be, he asked me. I knew that our MDs, who worked 25 hours a week, received about $75K in fees a year. Knowing how tedious it can be to review a case and how much time it took, I too wondered until that light bulb went off in my head.

If the physician, who was paid on a per-case basis for cases on which he made a determination, simply signed his name to the 60 cases he said he could close in an hour, that was it. He couldn't have been reviewing ANY of the information. He was robo signing the cases and, probably, denying all of them. Unethical? Yes. Fraudulent, most assuredly.

I gave my thoughts on the matter and pointed out that the MDs I knew who made these types of determinations could barely do three cases per hours. It was, literally, an impossibility to close 60 cases in an hour.

Of course, if you want to make lots of money and you have absolutely no problem with denying people coverage for which they are entitled, sending some of them to their deaths, I suppose it's possible. The guy should be in jail and all his property seized, plus he should be sued civilly by anyone denied by him.

So, watch the headlines as the Aetna cases progresses and hope that the other devious ones will be found out and punished.

#Aetna #insurancecoverage #reimbursement #insurance #healthcare #disability #scandals

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