Aetna Approves HMO Appeals

Aetna-U.S. Healthcare on Tuesday became the latest and largest health plan to allow consumers to appeal denials of insurance coverage to independent physicians.

Poised to become the nation's biggest HMO with its proposed purchase of Prudential Health Care, Aetna said it will be bound by the decisions of the external review committees.

Consumer groups praised Aetna's new policy, which starts in July, because it shows the HMO is placing medical concerns over the need to contain costs.

"This is a great move," said Charlie Inlander, president of the People's Medical Society, a national consumer health group based in Allentown, Pa. "It's something consumers have wanted for long time. It shows health care consumerism is really working."

Aetna has about 6 million HMO members, and would add another 2.7 million members with its purchase of Prudential. Eighteen of the 30 states where Aetna operates including Florida, Pennsylvania and New Jersey, already have laws that give HMO members the right to appeal to outside review panels.

For nearly a decade, the federal government has let Medicare HMO members appeal coverage decisions to an independent review board. President Clinton proposed a nationwide HMO external review system last year as part of his ill-fated HMO consumer protection bill.

Trying to respond to the outcry of HMO bashing, at least a dozen health plans have already adopted external appeals programs. But while consumers clamor for reforms, few actually seek the outside reviews.

Consumer groups were cautious about some aspects of Aetna's plan.

For instance, while consumers often complain about their HMOs, only a small percentage actually appeal decisions to the boards.

The consumer groups said the plan will work only if patients know about it and can easily access it. Aetna promises to heavily promote the option, which is available only after a patient has gone through the company's internal appeals system.

In addition, who chooses the review organization could be problematic. In some states such as New Jersey or Pennsylvania, state law requires the state to choose the review board. Where no such regulation exist, Aetna will choose.

Aetna will pay the cost of the reviews, which can range from $250 to several thousand dollars, except in those states which require consumers to pay a small filing fee.

Once all necessary information is submitted, external reviews will be decided within 60 days, though quicker responses will be available in urgent cases.

Writte By Phil Galewitz, AP Business Writer