AMA threatens Aetna suit over restraints on doctors Contracts alleged to compromise care

Health insurance


Aetna U.S. Healthcare came under fire from the American Medical Association yesterday in the wake of complaints from doctors in six states that the health insurer's contracts are illegal and compromise patient care.

If the alleged problems are not corrected, the AMA may file a lawsuit to try to force Aetna to make changes, the association said yesterday.

In a letter to Aetna, the doctors' group contends that the contract allows insurance company officials to override patient care decisions without an avenue of appeal.

The AMA also is upset that Aetna has the right to change its contract and patient care procedures without consulting doctors first.

Aetna officials said they are reviewing the issues raised by the doctors' group.

"I think there is an opportunity for us to go through and look at what we have in our contract and listen to what they said and make appropriate changes and modifications," said Aetna spokeswoman Jill Griffiths. "We don't necessarily agree that all of the points are accurate, but we still agree that we will look at it in every case."

Contrary to the doctors' allegations, Griffiths said, Aetna officials don't arbitrarily overrule treatment decisions. If care is denied, doctors and patients can follow a specific appeals process, she said.

"By and large, our medical directors don't know about treatments until after we get the claim," Griffiths said. "Doctors write referrals, members go to a hospital and then we see the claims."

The AMA's complaint follows similar protests recently to the Texas Department of Insurance. Aetna agreed to change several provisions in its contract with Texas doctors last month, after state regulators said the company violated state insurance laws and regulations.

In its Texas contracts, Aetna changed restrictions to increase patient confidentiality. The company also removed a clause that held doctors responsible for mistakes, even if they were made by the insurer, and deleted a provision that prohibited doctors from criticizing the health plan to their patients.

Griffiths said the "free speech" clause was never intended to prevent physicians from having open discussions with their patients. She said Aetna was trying to guarantee its members the same level of care as doctors give their other patients.

A spokesman for the Texas insurance department said the state was satisfied with the contract revisions.

Doctors in Ohio, New Jersey, Virginia, Arizona and Florida also complained to the AMA about Aetna's contracts. The group, which has 297,000 members, wrote Aetna on behalf of the Florida doctors in October. It has not received a response.

AMA board members said the Aetna dispute indicates of a growing trend among managed-care companies to ignore the interests of doctors and patients.

If physicians have problems with an insurer's contract, the usual response from the insurance company is "too bad," said Dr. Ted Lewers of Easton, the AMA secretary-treasurer.

"As in this contract, it's basically a take-it-or-leave-it approach," pTC Lewers said. "That concerns us because there are some issues in this contract that are not in the best interest of patients and not in the best interest of physicians."

The AMA will unveil a model managed-care contract at its House of Delegates meeting in Dallas Saturday. The document was drafted by a lawyer who has represented both insurers and doctors.

"We drafted this contract not to be a wish list for physicians, but to be a reasonable contract that balances the legitimate business needs of a plan with the ethical and legal needs of a physician," said Carol O'Brien, director of the AMA's division of representation.

Pub Date: 12/04/97

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