While such policies seem like a prudent way to deal with consumers who run to the ER with symptoms of a common cold, the reality is that it’s hard to draw a clear line in the sand.

Insurers have come under scrutiny in the past for policies rejecting claims for visits to the emergency room that they deem unnecessary. The latest to find itself in hot water? Aetna, which has been fined $500,000 by California’s Department of Managed Health Care after a sampling of claims from 2019 found it had denied 93% that it deemed unnecessary.

“The plan’s failure to follow California law for reimbursing emergency room claims is unacceptable,” said acting DMHC Director Mary Watanabe said in a press release. “This has resulted in Aetna wrongfully denying emergency room claims. Aetna must follow the state’s health care laws to ensure enrollees have access to the care they need.”

Complete your profile to continue reading and get FREE access to BenefitsPRO.com, part of your ALM digital membership.

Your access to unlimited BenefitsPRO.com content isn’t changing.
Once you are an ALM digital member, you’ll receive:

  • Critical BenefitsPRO.com information including cutting edge post-reform success strategies, access to educational webcasts and videos, resources from industry leaders, and informative Newsletters.
  • Exclusive discounts on ALM, BenefitsPRO magazine and BenefitsPRO.com events.
  • Access to other award-winning ALM websites including ThinkAdvisor.com and Law.com

Already have an account?

Emily Payne

Emily Payne is the current deputy editor for ALM's Business & Finance Markets and former managing editor for BenefitsPRO. A Wisconsin native, she has spent the past decade writing and editing for various athletic and fitness publications. She holds an English degree and Business certificate from the University of Wisconsin.

More from this author

 

BenefitsPRO

Join BenefitsPRO

Don’t miss crucial news and insights you need to navigate the shifting employee benefits industry. Join BenefitsPRO.com now!

  • Unlimited access to BenefitsPRO.com - your roadmap to thriving in a disrupted environment
  • Access to other award-winning ALM websites including ThinkAdvisor.com and Law.com
  • Exclusive discounts on BenefitsPRO.com and ALM events.

Already have an account? Sign In Now
Join BenefitsPRO

Copyright © 2023 ALM Global, LLC. All Rights Reserved.