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AMA SEEKS AETNA CONCESSIONS

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CHICAGO -- Charging that contracts between Aetna U.S. Healthcare and doctors in Florida allow the managed care company to "unilaterally change patient care," the American Medical Assn. is urging the managed care company to grant more rights to its physicians.

The AMA's letter, written Oct. 31 but only made public last week, criticized the Florida contracts on numerous fronts.

The AMA complaint represents a new, more aggressive stance by the Chicago-based physician group against what it deems to be the managed care company's encroachment on traditional physician decision-making turf.

Blue Bell, Pa.-based Aetna U.S. Healthcare said it is reviewing its contracts and would not get into a direct dialogue with the AMA due to "antitrust and other concerns."

The complaints initially arose out of inspections of the contracts by the Florida Medical Assn.; since then, attorneys representing doctors in five other states also have lodged complaints with the AMA about Aetna U.S. Healthcare's contracts.

The complaints include the charge that the contracts have an open-ended definition of "emergency services" that allows the company to deny coverage of necessary care.

Other provisions give Aetna U.S. Healthcare the authority to judge what services are covered, yet give to the provider "sole responsibility for care."

These provisions are contradictory because they "allow you to control patient care but avoid liability for the patient's outcome based on the results of your decisions," the AMA's letter said.

The contracts also put at risk of termination those physicians in the plan who attempt to appeal Aetna U.S. Healthcare's denials of care, especially those who treat difficult cases, the AMA said.

"These physicians face.*.*.an onerous risk of termination due to their increased need for patient advocacy," according to the AMA.

The AMA said it also objected to these provisions in the contracts:

*Gag clauses. Even though Aetna U.S. Healthcare last year announced it would stop the use of so-called physician gag clauses in its contracts, "the spirit of gagging physician communications to patients is still alive at Aetna U.S. Healthcare," because of rules banning doctors from indicating that managed care will lead to inferior treatment, the AMA said.

*Confidentiality. Although the contracts in question specify that all patients' health information should be completely open to the health plan, the AMA argued that "the medical record is the personal property of the physician and that the record is a confidential document involving the patient-physician relationship."

*Appeals. The dispute resolution mechanism outlined in the contract is very vague, contends the AMA. "Aetna is giving itself the ultimate power to supersede a physician's determination regarding the necessity of medical service and to deny even clearly needed medical care," the AMA said.

*Claims submission. Aetna U.S. Healthcare requires that claims be submitted within 90 days of services and that claims must be adjusted within 30 days of the original claim. The AMA says exceptions should be made for unforeseen circumstances and that Aetna itself should also be required to make timely payment on claims.

In a statement released last week, Aetna U.S. Healthcare said it had no interest in "negotiating contract terms with the AMA."

No gag clauses exist in the managed care company's contracts, it stated.

To avoid any confusion, clauses prohibiting doctor-patient discussion of how managed care affects quality of care already have been eliminated, according to Aetna U.S. Healthcare.

The company also said that despite the AMA's desire for records privacy, the company has an absolute right to review patient records for such purposes as quality assessment, credentialing and disease management.

In addition, the company rejected the notion that appeals processes are not available to Aetna U.S. Healthcare, pointing out that grievance processes are required by state and federal law and are in place in every Aetna U.S. Healthcare HMO.

It also defended its emergency care rules, arguing it has adopted the "prudent lay person" definition of an emergency for all its HMOs, as set forth in the Balanced Budget Act of 1997.