Aetna medical director NEVER looked at patients's records

[Katers87]

Perhaps. I guess I envisioned that if medical necessity were the same from insurance company to insurance company, there could still be an appeals process to dispute a claim denial due to medical necessity.

It’s unlikely it’ll happen anyway

[Michel]

@Katers87

It sounds like Aetna said he needed bloodwork done because it had been 3 years since he’d last had bloodwork done. I don’t know anything about his condition, but if they’re forking out $20,000 for each treatment then it seems pretty reasonable to require that the patient get bloodwork done regularly.

@Katers87, I agree that the patient screwed up and should have done what was asked.

But this is not the part that bugs me. What bugs me is that the doctor never looked at the patient records once in three years. That fact was discovered in the process of discussing the case, and it is that facts that shocks me.

I am not sure if the patient should win his case. But, in my mind, a doctor who makes calls on preauths and appeals should read the patient records, and it is incredible to me that he did not feel the need to do so in 3 years of working at Aetna.

[bkh]

@Katers87

The article does say, “Aetna medical directors are trained to review all available medical information – including medical records – to make an informed decision. As part of our review process, medical directors are provided all submitted medical records, and also receive a case synopsis and review performed by a nurse.”

The part they left out is that the medical director has an average of 700 cases to decide each day. (I just made that number up, but I suspect that an unreasonable workload is a factor in the extent to which the physician will carefully review the underlying medical files before deciding to just rubber stamp the staff recommendation.)