A peek into the back room

By John Greenbaum, National Employee Benefits Practice Leader

A peek into the back room

When we talk with clients and prospects about their benefits program, there’s an understandably large percentage of the conversation that revolves around managing escalating costs. That line of discussion, in turn, typically brings the conversation around to employee impact and ensuring the benefits provided are actually beneficial. We’re talking about people’s health and wellbeing, after all.

So it’s perhaps a bit unnerving, if not wholly unsurprising, that the country’s third largest health insurer seems to make its benefit payment decisions with a bit less considered deliberation.

Over the weekend, CNN reported that it had obtained testimony given under oath by Dr. Jay Ken Linuma, who’d been Aetna’s medical director for Southern California from March 2012 to February 2015. In that testimony, Dr. Linuma testified that he did not look at patient records when deciding to deny coverage. He testified that he followed Aetna training in which nurses reviewed records and made recommendations to him.

The testimony was given in the course of a lawsuit instigated by a patient insured at the time by Aetna who was denied ongoing treatment for a rare disease. The denial was eventually overturned, but the delay had consequences and the reasons for it should be unsettling for anyone involved in benefits administration because it’s unlikely Dr. Linuma and Aetna are outliers in this regard. All insurers are presented with complex claims requiring review. As consumers we understand that the insurer’s economic interests are not always aligned with our own, but we trust that their decision making process always operates in the best interest of the patient. In the case of Aetna’s process, we may be inclined to draw other conclusions.

Aetna denies what Dr. Linuma testified to is standard practice. The state commissioner has opened an investigation. Is it any wonder that company’s with the power to do so – like Amazon, Berkshire Hathaway and J.P. Morgan – are looking for alternatives to the status quo in health care access? We hear the frustration constantly with clients and find them increasingly open to new ideas that might promise better outcomes for their employees and their business.

The contents of this article are for general informational purposes only and Risk Strategies Company makes no representation or warranty of any kind, express or implied, regarding the accuracy or completeness of any information contained herein. Any recommendations contained herein are intended to provide insight based on currently available information for consideration and should be vetted against applicable legal and business needs before application to a specific client.