On Jan. 1, 2014, Mike Barnhill, deputy commissioner of the Department of Administration, implemented a new appeal process for the state’s AlaskaCare Health Plans. He stated in a town hall meeting that this was done because Division of Retirement and Benefits personnel who oversee the AlaskaCare Health Plans were making medical decisions on claim appeals without medical knowledge.
In July 2015, two meniscus tears were repaired in my left knee. Anyone who has had painful meniscus tears knows that only surgical repair can be done to fix the damage. My health insurance, AlaskaCare, denied coverage for the surgery saying that it was not medically necessary (according to their third party administrator, currently Aetna, using their proprietary “Coverage Policy Bulletins”). The surgical center and anesthesiologist’s bills were both paid! That’s another Letter to the Editor story…
I appealed to Aetna two separate times (as required by the plan before appealing to the Office of Administrative Hearings), which takes months and months. Both appeals were denied. Then, almost one year after the surgery, I appealed a final time to the Office of Administrative Hearings, the final appeal rights afforded to AlaskaCare covered members after Jan. 1, 2014. Amazingly, when my appeal reached the Division of Retirement and Benefits, their “Chief Health Official” determined that the surgery was medically necessary and AlaskaCare paid the surgeon. No Office of Administrative Hearings appeal! I received the notice of payment from Aetna a full three weeks before I received my official letter of notification by the Division of Retirement and Benefits, signed by the State’s “Chief Health Official”.
My point, if medical necessity determinations are still being made by non-medical people within the Division, through a process that is neither offered in the plan nor notified of being available, then why change the appeal process? If Mr. Barnhill would have only checked with General Services he could’ve seen proof that the State’s previous process on administrator appeals for medical necessity was to have an Independent Review Organization physician review those claims as a contractor working for the plan. Who’s minding Aetna’s coverage of AlaskaCare benefits, and how has the change in appeals helped? How many retirees’ claims have been denied in error when they would be covered if the Plan Administrator simply saw them? While Aetna should not be allowed to make determinations based on their own commercial “Coverage Policy Bulletins”, especially when their denials are overturned quickly and soundly by the Division of Retirement and Benefits, over a year later, by someone who is not a medically trained person, changing the entire appeal process was not the answer.
Oversight of the plan’s third party administrators’ actions is the state’s responsibility. If changes to processes are made, they should make the health plan better, not worse. And truth should always be in the forefront.
• Freda Miller is a Customer Service Team Lead for Aetna (AlaskaCare) 1997-2004, and a Benefits Manager, Division of Retirement and Benefits 2004-2009.
