Ensure your company is protected with the right software! // Aetna, the nation’s third-largest insurance provider with 23.1 million customers, is under fire from an investigation led by the California Insurance Commissioner, Dave Jones. While Group Health is already a stringent practice that requires adherence to several laws and regulations, one of Aetna’s reviewing physicians admitted under oath that he had never reviewed patient medical history prior to denying any treatment/medication request. Aetna could face severe monetary penalties due to their physician’s negligence. This investigation could also lead to further implications in other highly regulated industries statewide. Namely Utilization Review in workers’ compensation because of the similarity in nature.

Utilization Review has strict regulations stating what an entity must report when making a treatment approval or denial. The California Department of Industrial Relations, or DIR, states “Any time a written decision modifying, delaying, or denying treatment authorizations shall be provided to the requesting physician, the written decision shall contain a list of all medical records reviewed”. This excerpt emphasizes why it is important to review medical history and other documents related to a patient when making determinations. If the reported Aetna case had been for a Utilization Review request, then this specific reviewing physician would not have had any supporting documents submitted to show whether the patient’s medical history was reviewed. Aetna’s reviewing physician’s actions have created a shock in the medical community. The ensuing investigation could eventually lead to stricter regulation in many different facets across the state and potentially other states as well, not only in group health but possibly in workers’ compensation and other industries alike.

How can other providers or reviewing organizations prevent something like this from happening in the future? The short answer is to start by enforcing a strict internal protocol, and to then have a medical software system that can establish a level of accountability for its users. DataCare’s Ahshay Software was built for the Utilization Review workflow, with the ability to track who was logged in and what they viewed (treatment history, medical history, documents, reports, bills), what was sent out from the system, and be able to turn all this data into actionable information.

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