Aetna U.S. Healthcare To Institute First Voluntary External Review Policy For Managed Care
BLUE BELL, PA, January 12, 1999 — Aetna U.S. Healthcare, the health business unit of Aetna (NYSE: ΑET), today announced plans to become the first national managed care organization to voluntarily provide for external review of coverage decisions. Under the policy, members of any Aetna U.S. Healthcare commercial HMO, QPOS® or USAccess plan will have the right to appeal coverage denials to neutral, independent physician reviewers.
The company plans to have the external review arrangements in place for all Aetna U.S. Healthcare commercial HMO and QPOS® members in those states not already covered by external review legislation by June 30, 1999. Aetna U.S. Healthcare's new external review policy is the first to be implemented by a national managed care organization across all of its plans.
"Aetna U.S. Healthcare is committed to raising the quality of healthcare in America and this new policy further demonstrates our dedication to reaching out to make sure that our members get the healthcare they need," said Michael J. Cardillo, president of Aetna U.S. Healthcare. "External review provides members with the comfort that an additional timely response mechanism is in place to help ensure that our members get the care they need when they need it. While statistics show that few members will ever need to use this process, we want to provide them with the added security that external review is available should that rare instance occur," Cardillo said.
Aetna U.S. Healthcare already offers members an opportunity for a comprehensive and thorough internal review of coverage decisions. The expanded policy, which will be actively communicated to all members, will permit members to request external reviews after the first and second level internal appeals have been completed. Once all necessary information is submitted, external reviews will be decided within 60 days.
"If a neutral expert sees things differently than we do, we want to know in real time so that swift action may be taken," said David F. Simon, Chief Legal Officer, Aetna U.S. Healthcare. Expedited external reviews will be available when a member's life, health, or ability to regain maximum function would be in jeopardy if a decision were not rendered before the 60 day period elapses. "Delay serves no one's interests, and this review policy enables rapid response to our members' concerns," Simon said.
The policy will also allow any licensed physician to request an external review on behalf of a member, provided that the member consents to their doctor's representation.
"I believe external review will bring a new degree of trust into the relationship among physicians, members, and the health plan," said Dr. Arthur Leibowitz, Chief Medical Officer, Aetna U.S. Healthcare. "This policy not only reaches out to protect the interests of the member involved in a specific case, but by bringing us the input of an independent expert, it will help us gain greater understanding about how managed care can work best for the consumer."
Aetna U.S. Healthcare will bear the cost of independent reviews, except in those states which have legislated a filing fee. Members may request an external review if Aetna U.S. Healthcare denies coverage after the internal appeals panel has determined that the proposed service is unnecessary, inappropriate, or experimental in nature. Certified independent review organizations or similar organizations will be used, and the reviews will be conducted by neutral, independent physician reviewers with appropriate expertise in the area in question. Where permitted by law, the fair and unbiased decision of the external reviewer will be binding on both the plan and the member.
Aetna U.S. Healthcare is the nation's leading health and related benefits organization, providing a full spectrum of products ranging from health maintenance organizations (HMO) to indemnity health insurance, group life and disability products, and dental, vision, and pharmacy benefits to approximately 16 million Americans. In addition, Aetna U.S. Healthcare provides quality measurement and improvement programs and data analysis for providers and purchasers of health care. www.aetnaushc.com
For more information about Aetna Inc., please visit the company's website at
www.aetna.com.
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