New York medical society takes insurers to task

Westchester County (N.Y.) Medical Society is presenting its complaints about denied claims to state authorities to force HMOs to pay up.

By Cheryl Jackson, AMNews staff. April 16, 2001.

Having recently worked with state regulators to get Aetna to overturn some denied claims decisions, the Westchester County Medical Society in New York is using a similar approach to get the attention of other insurers.

The group is using complaint information it has collected from physicians across the state to prove patterns of abuse with claims payments.

Aetna, according to the society, had refused to pay some claims, maintaining that the physicians did not get adequate referrals. The complainants, though, said they did have referrals.

Using the medical society's findings, the Office of the Attorney General in February got Aetna to agree to review claims for doctors and patients it had denied in 1999 and 2000 citing lack of referrals.

"They've agreed to pay [resubmitted claims] if there is evidence that there was a valid referral at the time," said Troy Oechsner, a health care bureau chief for the attorney general's office.

Rob Kremer, an Aetna spokesman, said that in most of the cases presented, doctors did not submit referrals to the insurer quickly enough.

Members of the county medical society also presented complaints to Empire HealthChoice Inc. at the insurer's annual meeting in March. Westchester County Medical Society president, Peter Liebert, MD, said the society had documented payment abuses by Empire. [...]