Aetna fined for denying ER claims in California

Aetna Health of California must stop using national standards to deny payment for emergency room claims, the California Department of Managed Health Care ordered Aug. 25. 

The department said the practice has led to Aetna wrongfully denying ER claims because California's broader standards on ER services aren't being applied. Aetna faces a $500,000 fine for repeatedly not following California law and failing to implement improvements.

Under California law, health plans must pay for emergency medical services unless there is proof the services didn't occur or an enrollee didn't need ER care. The department reviewed a sample of Aetna's denials for ER services and found 93 percent of the sampled claims were wrongfully denied.

The department has previously fined Aetna for improperly denying ER claims. In 2015 and 2016, Aetna entered into settlement agreements with the department and paid $135,000 in fines.

In an emailed statement to Becker's, Aetna said: "We are committed to providing our members with appropriate access to emergency room services and to complying with all laws applicable to our business. For medical emergencies, our members should utilize the nearest emergency room facility. We have taken a number of steps to help ensure that we handle emergency room claims consistent with California's standard for determining whether an emergency medical condition exists. We are cooperating with the California Department of Managed Health Care in this matter."

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