Yesterday, CNN posted an exclusive article regarding the regulatory fallout stemming from the recent testimony given under oath by one of Aetna’s former medical directors. During his sworn testimony, a former medical director admitted to never having reviewed patients’ medical records during appeals of coverage determinations, stating that he was merely following “Aetna protocol.” The testimony was given by the former Aetna medical director in connection with a patient’s longstanding lawsuit brought against Aetna for denying pre-authorization of a continuing course of infusion medications for Common Variable Immunodeficiency (CVID), a lifelong immune system disorder. In denying the prior authorization, the patient claims that Aetna ignored the appeals his doctor filed on his behalf and that Aetna’s “withholding of benefits almost killed him” when he was hospitalized with a collapsed lung sometime after prior authorization appeals for the CVID treatments were originally denied. These shocking revelations have now led at least the California Insurance Commissioner to launch an investigation into Aetna’s practices.
Although health care providers and their patients constantly experience similar industry-wide issues with Pharmacy Benefit Managers (PBMs) and insurers during prior authorization review and appeals, not enough has been done to curtail the often illegal, arbitrary, capricious, and potentially life-threatening policies and practices that these administrators adopt. Even though providers have stood up to such conduct behind the scenes, they are also regrettably limited as to what they can do under the law to firmly address and correct the behavior. Contracted or “participating” providers are particularly subject to overbroad confidentiality and/or arbitration clauses which often place a chilling effect or “gag order” on their ability to disclose basic information about such conduct—even to governmental authorities. As such, patient-provider appeals and lawsuits are becoming increasingly more critical in ensuring that insurers and PBMs are playing by the rules as the administrative gatekeepers of health benefit plans—including those established by ERISA—in discharging their various duties owed to patients, plans, and providers.
Frier Levitt is committed to assisting providers and employers in being staunch advocates for their patients and beneficiaries to ensure that administrators are putting the beneficiaries’ best interests in front of their own financial or other interests. If you are a health care provider or employer that is experiencing similar problems with the way in which administrators are handling coverage determinations or prior authorization appeals for your patients or beneficiaries, contact Frier Levitt today to speak to an attorney.