Aetna Medical Director Denies Care Without Reading Submitted Medical Records

It is sort of rare to see any kind of “stunning admission” by an insurance giant. But this week’s headline about an Aetna Medical Director who made important decisions on claims without reading the medical records has been met with mounting frustration over lack of quality in payer review.

In the CNN story, Dr. Anne-Marie Irani called the admission incredible. Another physician, Dr. Andrew Murphy, states that the revelation may actually prompt changes to the system.

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AppealTraining.com Featured Letters

The AppealTraining.com website has letters which cite the URAC standards related to appeal review and peer coversation. The URAC appeal letters are under the collection under Topic: Medical Necessity, Subtopic: Case Management Standards. These letters can be used to request peer conversation or to contest a poor quality peer conversation process:

1. Appeals Consideration
2. Lack of Appeal Response
3. Lack of One Day Response
4. Lack of Timely Decision
5. Lack of Written Decision
6. Peer-to-peer Conversation
7. Records Request Response
8. Reversal of Certification Determinations

Be sure and review the letters under Topic: Medical Necessity, Subtopic: State Medical Necessity Terms for additional state regulations applicable to peer review.

Visit AppealTraining.com's Database of 1600+ Letters

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Are you ready to start demanding a high quality medical review process from payers? Do you want to make sure that when you submit records, they are not just read by payers but also understood?

Tammy Tipton, President of Appeal Solutions, will discuss how to assess appeal responses for signs of a poor quality review in the upcoming webinar, “Medical Necessity Appeals And Demanding A Quality Review By The Payer.” The webinar will be April 10 at 11 pm CST. Strategies for demanding peer review, peer discussion, expert review and complete clinical disclosure will be explained.

Level II medical necessity appeal customizations will be demonstrated so that none of your higher level appeals are rejected due to "no new information." Further, participants will be given 14 medical necessity appeal letters to make it easy to use these well-worded demands for quality review.

Sign up today for this webinar and get a FREE 30-Day PRO AppealTraining.com Membership and 1 CEU Credit. You'll get unlimited access to over 40 video training courses, 1600 appeal letter templates, and much more! Sign up today to attend our Medical Necessity Webinar for only $297.