Aetna Under Scrutiny as Medical Director Admits to Never Reviewing Medical Records Before Denying Care

I don’t know if you’ve heard, but the 3rd largest health insurance company, Aetna Healthcare, is under scrutiny after a former Medical director admitted under oath that he never looked at patients’ records when deciding whether to approve or deny care.

This admission was made during a deposition in a lawsuit brought against Aetna by Gillen Washington, a 23-year-old, diagnosed with immune deficiency and denied coverage for important healthcare procedures.

The medical director said he was following Aetna’s training, in which nurses reviewed records and made recommendations to him. He also admitted that he had minimal if any knowledge at all of the medical condition that Gillen suffered from.

If you, like me, have experience dealing with insurance companies this news from Aetna will probably not come as a surprise. It sure is no surprise to me.

I used to own an insurance billing company for over 15 years so I’ve seen it all.

I’m Madeleine Silva and for those of you who don’t know me, I teach doctors, healers & practitioners how to thrive in today’s rapidly changing, patient-driven economy. Because it’s not business as usual.

The irony is that the US spends more money on healthcare than any other country in the world, yet is only ranked as 37th in quality of care.

A baby born in the US is less likely to see it’s first birthday than a baby born in Belarus, Slovakia or even Cuba.

So much of the bad stuff that happens in healthcare is because insurance companies are largely dictating how healthcare needs to be delivered.

Talk to any provider, no matter their specialty, they will all agree that dealing with insurance companies is the biggest headache of being in practice.

Much of the staggering cost of healthcare has been blamed on greedy healthcare providers trying to take advantage of the system and overbilling.

But that’s not true at all.

Because in reality, Providers billing practices are a direct result of insurance companies slashing reimbursement rates while enforcing visit limitations.

Healthcare services that used to be reimbursed at $70-$100 10 years ago are now reimbursed around $16 or $20.

Ten years ago, you could send a bill to an insurance company and expect to get paid in 10 days. Today that same claim may be lost, denied or at the very least delayed for who knows how long.

The cost of owning and operating a brick and mortar practice in today’s digital world keeps going up and reimbursement rates keep going down, patients are demanding more time and more personalized care.

You may wonder how does a doctor, healer or practitioner survive in private practice?

And before you start yelling ‘CASH practice’

It’s not quite as easy as that, is it?

Because if most of your new patients come to you from the insurance company lists and insurance reimbursements are a big percentage of your practice revenue, you can’t just stop taking insurance and expect to stay in business.

But at the same time, it’s not like you got into practice to have insurance companies dictate how to care for your patients or how much you can charge for your services.

But making the transition to a cash practice takes time and a well thought out plan.

The very first thing you need to do to establish yourself as a cash practice is:

  1. Make sure you’re competing on MUCH MORE than cost for care.

    How good are you at communicating your value and how you’re different from the doc down the street? Or are you the best-kept secret in your town?

  2. Have a steady stream of new patients.

    Making changes can be stressful. You worked hard to build your practice up to this point and of course, you don’t want to do anything that will jeopardize what you already have going on.The best way to calm the nerves is to have the phone ringing with new patients. So, it’s important that you expand your marketing efforts to reach patients that are not picking you solely because you’re on their insurance plan while you begin transitioning over to a cash practice.

    With 81% of people on Facebook and 94% of patients picking providers from online reviews – you need to build a strong presence online.

    If you’ve been tuning in to the conversation in the Healthcare Heroes Facebook group, you know I’m a strong advocate of Facebook live video as a way of connecting with potential patients and building a solid reputation as an expert in your community.

    I frequently lead our community of Healthcare Heroes through a 5-Day Facebook Live Challenge. This is a perfect challenge for those of you that have been thinking about doing Facebook live video but wonder what to talk about, or how it works. You may need a little nudging and lots of support.

    I give you a topic to share about each day together with step-by-step instructions on how to make your Facebook live video attract your dream patients. All you need to do to is join Healthcare Heroes.

  3. Create a step by step cash practice transition plan

    The absolute worst thing you can do is to get fed-up and just quit insurance from one day to the next. Doing that can seriously disrupt your cash flow and send you right back into survival. At the same time, don’t let your fear of what might happen if you transition into a cash practice stop you from making the necessary changes. Look at your numbers to find out what insurance company do you rely on the heaviest? Which one impacts your business bottom line the least? Make a list from top to bottom of all the payers you currently bill.

    Begin by going out of network with the insurance company you work with the least, then work your way up the list.

    As your marketing strategies begin to deliver, let go of more of the insurance reimbursements.
    Once you’re out-of-network with all of the payers, begin to stop taking insurance altogether. Refer back to your list and begin with the insurance company that impacts your practice the least.

    There are nuances to this general plan, but this is a good start.  If you need help just schedule a  Free Clarity Call with me and I’ll help you prioritize and create a realistic timeline to create your cash practice.

    Until next time, Be a Healthcare Hero.


 Madeleine Silva - Healthcare Hero

Hi, I’m Madeleine Silva. I teach chiropractors, dentists, physical therapists, medical doctors, naturopaths and other doctors & healers how to thrive in today’s rapidly changing patient-driven digital economy. Because it’s not business as usual. If you want to be part of a group of forward-thinking health professionals on a mission to transform healthcare – join us at Healthcare Heroes