Aetna Inc. erected the fewest number of roadblocks for medical patients seeking special treatments of any Connecticut health maintenance organization in 2006 ”“ and in cases where it rejected a treatment, had the fewest number of appeals reversed.
Health maintenance organizations (HMOs) use a process called utilization review in approving or denying requests for treatment. Members can appeal denials to the Connecticut Department of Insurance.
Aetna”™s HMO had the lowest number of utilization review requests in the state, the process by which insured members request a special procedure from a specialist. The Hartford-based company denied just 7.4 percent of such requests last year from its HMO members.
Anthem Blue Cross and Blue Shield, a business unit of Indianapolis-based WellPoint Inc., rivaled Aetna Health with a 7.6 percent denial rate. But while Aetna Health had just 13 cases reversed on appeal, or in 5.7 percent of cases, the Connecticut Insurance Department reversed Anthem decisions on 553 cases, just above half of all cases that Anthem members appealed.
In all, 0.6 percent of the 92,700 total number of requests by Anthem members for utilization review ended up reversed on appeal by the Connecticut Insurance Department.
Despite Anthem”™s utilization review record, the insurer trailed only Health Net Inc. in a Connecticut Insurance Department survey asking members to rate their carrier. California-based Health Net has its main Connecticut office in Shelton.
Trumbull-based Oxford Health Care L.L.C. fared only slightly better than Anthem in its utilization review practices, with the Insurance Department reversing Oxford”™s decisions on 0.5 percent of its HMO members”™ total utilization review requests.
Oxford has the largest network of physicians and specialists in Fairfield County. In 2004, the company was acquired for $5 billion by UnitedHealth Group Inc. Last month, Connecticut and 36 other states reached a $20 million settlement with the Minneapolis carrier over claims practices, which did not involve Oxford”™s systems.
Experts say the utilization data are seldom scrutinized by small companies that offer group policies for their employees, with owners and personnel managers keeping costs at the forefront of considerations for health-care decisions.
“I think the managed-care report card is underutilized by purchasers of insurance,” said Kevin Lembo, Connecticut”™s health-care advocate. “It is a huge task, for anyone pulling together a health plan for their employees to do the due diligence, ask the right questions and make an informed decision. It”™s a leap of faith.”
“Unfortunately, most of the small businesses we talk to ”¦ are really looking for anything they can afford at all,” agreed Ellen Andrews, executive director of the Connecticut Health Policy Project.
Coverage is nonetheless an important recruiting and retention tool, particularly for smaller finance and professional services firms that attempt to keep benefits on par with financial conglomerates from which they recruit.
“Hedge funds ”¦ don”™t want their employees to have to deal with that kind of minutia,” said Angie LeMar, director of group benefits for Lennox Advisors, a New York City firm that recently opened a Stamford office.
Aetna”™s most recent utilization review record carriers may be listening to the market ”“ in 2005 the Insurance Department reversed 122 appeals of Aetna”™s HMO utilization review denials, roughly 10 times the number last year.
“I”™d like to think that some companies see that they have a problem area and take steps to correct it,” Lembo said.
Â
Â
