Claim Paying History

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With all the different major medical plans out there, claim history is important. Now I've heard from 2-3 different agents/formerly did billing/ who say Aetna was difficult to work with to pay claims. Now here is this article. Is this criticism valid?

Aug. 16, 2007, 4:53PM

NY AG Warns Insurers on Doc Rankings

By CAROLYN THOMPSON Associated Press Writer

© 2007 The Associated Press

BUFFALO, N.Y. -- Attorney General Andrew Cuomo asked Aetna Inc. and Cigna Corp. on Thursday to explain how they recommend doctors to patients after finding the insurers' physician-ranking programs to be confusing or even deceiving.

"Ratings can be a very good thing if these ratings are accurate and fair and transparent. The more information to the consumer the better," Cuomo said during a conference call with reporters. "But we want information that is helpful to the consumer and in the consumer's best interest."

In letters to the Connecticut-based insurers, Cuomo took issue with their use of claims data, which is provided to the companies by physicians seeking payment, in ranking specialists such endocrinologists, neurologists and cardiologists.

The reliance on claims data, which does not contain complete clinical information, can skew rankings, Cuomo said. He also took issue with the insurers' failure to disclose the accuracy rate of their rankings, noting that insurers "have a profit motive" to recommend doctors who cost less but are not necessarily the most qualified.

For example, a diligent doctor who orders an additional test may be branded as expensive and fall in the company's rankings.

"Absent review of relevant clinical data, you are unlikely to know why the additional test was ordered," the letter from Cuomo's office said.

Insurers were asked to detail the criteria used to rank physicians and explain how they measure a doctor's performance and cost-effectiveness and what incentives are used to steer patients toward or away certain providers.

"We will cooperate fully. Aetna is fully committed to transparency," Aetna spokeswoman Cynthia Michener said.

She said the company's "Aetna Aexcel" network is limited to specialists in 12 areas and does not include primary care doctors.

"Doctors are designated if they meet certain thresholds first for clinical performance and, only then, cost efficiency," Michener said. The criteria is published on Aetna's member and provider Web sites, she said.

A spokesman for Cigna said the company was reviewing the attorney general's letter.

"We take the attorney general's concerns seriously and will respond to his request for information," spokesman Wendell Potter said.

Last month, Cuomo instructed United HealthCare not to introduce a physician ranking program in New York state without his approval.

"The health care companies have an economic interest in seeing the customer go to the doctor or institution that charges the least amount of money," Cuomo said. "Cheaper is not necessarily better and we don't want a health care system where we enter a race to the bottom."

He compared insurers' rankings of doctors to the practice of colleges recommending certain lenders to students while accepting gifts from the lenders, a practice he condemned earlier this year.
Despite all the articles I've read and movies like Sicko I have yet to have a single major claim denied or not paid by any of the carriers I work with.
Carriers do not capriciously deny legitimate claims. There are too many legal issues involved.

They will routinely challenge borderline claims, especially on individual policies where pre-ex is an issue. Some carriers automatically deny any illness related claim filed in the first 6 months or so the policy is in force and wait on the policyholder to request a review. If none is requested the carrier feels it has justified their position that the claim was pre-ex. Even if a review is requested, many times it is up to the policyholder to prove the claim is not pre-ex if they want it paid on a timely basis.