By Meena Kaypour

On August 25, 2020, the Department of Managed Health Care (DMHC) issued a cease and desist order to Aetna Health of California, Inc. with respect to its continued failure to comply with California standards for emergency room coverage, and fined the health care provider $500,000. As alleged in DMHC’s accusation against Aetna, Aetna repeatedly failed to apply California law and implement corrective action plans agreed to in 2015 and 2016. DMHC also ordered Aetna to correctly reprocess all of its emergency room denials dating back to February 1, 2017. In a press release announcing the order and fine, Acting Director Mary Watanbe stated, “The plan’s failure to follow California law for reimbursing emergency room claims is unacceptable. 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.”

According to the August cease and desist order, in 2010, Aetna applied its national “prudent layperson” standard set forth in the federal Balanced Budget Act of 1997, and applicable state law standards, to deny coverage for 23 separate emergency medical services. The national “prudent layperson” standard allows Aetna to deny payment for an emergency room visit unless the medical record shows that a prudent layperson with an average knowledge of health and medicine would have known that his or her condition was truly an emergency. The California standard, under the Health and Safety Code sections 1371.4(b) and 1371.4(c), requires a plan to pay for an emergency room visit unless it has evidence to show that emergency services were not performed, or the enrollee did not require emergency health care services and reasonably should have known that an emergency did not exist.

In the accusation, DMHC alleges that Aetna agreed with DMHC to implement an informal corrective action plan (CAP) to reform its procedures for adjudicating claims, agreeing they had not applied the California standard. In 2015, DMHC ordered a second corrective action plan asking Aetna to pay a $10,000 administrative penalty and enter into a CAP that required Aetna to train employees adjudicating claims to apply the California standard. Again in 2016, Aetna denied coverage for eight claims for medical services and was ordered by DMHC to pay a $125,000 administrative penalty and implement a CAP to reimburse emergency medical services based on the California standard. In four instances between 2017 and 2018, Aetna continued to apply the national “prudent layperson” standard to California cases. In 2019, DMHC’s survey report of Aetna denied cases found 93 percent of the sampled emergency claims were wrongfully denied.

DMHC is charged with the regulation of managed care organizations operating in California and ensuring that the entities that sell health care service plans are in compliance with Health and Safety Code sections 1341(a) and 1345(f), also known as the Knox-Keene Health Care Service Plan Act. According to DMHC’s press release, consumers should file a grievance with their health plan if the health plan denies payment for emergency services. The health plan will review the grievance and should ensure the plan is following the California standard of emergency care. If a consumer does not agree with their health plan’s response or if the plan takes more than 30 days to fix the problem, consumers can file a complaint with DMHC’s Help Center at www.HealthHelp.ca.gov or 1-888-466-2219.