DALLAS, TEXAS, April 11, 2000 — (NYSE: ΑET) Aetna U.S. Healthcare today announced that it will establish a consumer ombudsman office for Texas HMO members, provide Texas physicians with additional choices in product participation, and clarify how medical necessity and coverage decisions are made in a groundbreaking agreement with the Texas attorney general. These provisions are the result of months of discussions and negotiations with the office of the attorney general on the development of appropriate guidelines for HMO operations in Texas.
"We are very pleased that we’ve been able to work cooperatively with the attorney general to address issues of primary importance to consumers and to help strengthen our relationships with physicians," said Arthur Leibowitz, M.D., chief medical officer of Aetna U.S. Healthcare. "Our agreement with the Attorney General underscores that our members’ health care needs are our first priority -- an important step in strengthening the trust of our members and participating physicians.
"While many of the provisions in this agreement reflect current practices at Aetna U.S. Healthcare’s Texas HMOs, we felt it was important to better inform the public of our policies and to create new initiatives when it benefited consumers," continued Leibowitz. "The company is in the process of studying the feasibility of these new initiatives in other markets outside of Texas."
The agreement is expected to accomplish two of Aetna U.S. Healthcare’s overriding goals: to improve its relationships with physicians, and to increase public understanding of HMO policies and procedures.
Consumer highlights of this agreement include:
- expanding external review to include appeals for experimental and investigational coverage, emergency coverage, prescription drugs and standing referrals to specialists,
- creating an office of the ombudsman for Aetna U.S. Healthcare's Texas HMO members that will act as an advocate and provide assistance on appeals or complaints,
- clarifying that medical necessity decisions are based on state-of-the-art standards that are publicly disclosed and made by Texas-licensed physicians,
- ensuring that physicians will apply the same standard of care to all patients, regardless of benefit plan or type of coverage, and
- implementing programs and studies designed to detect and prevent underutilization of health care services, especially as it relates to women, minorities and members with chronic illnesses.
Physician highlights of this agreement include:
- allowing individual physicians to choose whether they want to participate in all of Aetna U.S. Healthcare’s product lines,
- providing 90 days' advance notice of significant changes in policies or practices impacting a physician's participation in Aetna U.S. Healthcare's networks, and
- enhancing financial protections for physicians with fewer than 100 HMO members who currently are paid on a capitated basis (fixed per-member per-month payment) by paying them on a fee-for-service basis.
