The recent $25.6 million verdict against Aetna insurance company exposes another flaw in the payment systems of US healthcare. The gist of the case is that Aetna denied coverage for proton beam therapy for stage 4 nasopharyngeal cancer which the plaintiff argued as showing bad faith by Aetna to the insured, who died before the verdict. Evidence showed that Aetna’s denial of the claim involved overworked and possibly under-qualified doctors. The reviewers were working in the interest of their employer’s bottom line, and the employee receives pay based in part on the profitability of the company. This part should come as no surprise as an employee is working for the benefit of their employer as much as or sometimes more than working for the benefit of the insured or the customer.
This conflict of interest issue is another part of the complexity of our health payment system. Payers should always have the right to review claims, reduce fraud and save money. However, who does this and how it is done is not as easy as some might think it should be. Even with government-sponsored payers and non-profits, the conflict can still be present. How the review of claims and the reduction of fraud must be continually reviewed in and of itself by payers of all sorts, public and private, non-profits and for-profits. When there remains such a large amount of money sloshing through the health system daily, there must be a standard method devised by insurers and providers, who are smart people, to make decisions regarding necessary and unnecessary procedures fairly and honestly. As a first step, the pre-authorization processes must become more transparent and standardized across payers along with claim denials and appeals processes. The payer cannot withhold authorizations and payments in order to make more money for themselves as may very well be true in some instances without regard for the value of the life and health of the insured.