According to Former Medical Director, Aetna, Nation’s Third Largest Insurer, Doesn’t Review Medical Records When Deciding Whether to Approve or Deny Coverage

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California’s insurance commissioner has launched an investigation into healthcare provider Aetna after a former medical director testified under oath that he never looked at patients’ records when deciding whether to approve or deny care.  The former Aetna official said that per the company’s training, he relied on nurses who reviewed individual patients’ records and made recommendations to him.

Dr. Jay Ken Iinuma served as medical director for Aetna for Southern California from March 2012 to February 2015.  In that time, Iinuma said that virtually all of his work was conducted online.  When asked how many times he might call a nurse to ask for more details in the course of a month, Iinuma responded “zero to one.”

Aetna in its legal brief, defended the practice, saying that in his time at Aetna, Iinuma followed the company’s Clinical Policy Bulletin appropriately.

“Given that Aetna does not directly provide medical care to its members, Aetna needs to obtain medical records from members and their doctors to evaluate whether services are ‘medically necessary.’ Aetna employs nurses to gather the medical records and coordinate with the offices of treating physicians, and Aetna employs doctors to make the actual coverage-related determinations,” the company wrote.

Iinuma has been called to testify in the case of a California man who suffers from a rare immune disorder called common variable immunodeficiency, or CVID.  The man, Gillen Washington, 23, is accusing Aetna of breach of contract, saying he was denied coverage for an infusion of intravenous immunoglobulin (IVIG) when he was 19, causing him to be hospitalized with a collapsed lung.  In a videotaped deposition, Iinuma, who signed the order denying Washington’s coverage, said he never reviewed his medical records and knew little of his disorder.

California’s Insurance Commissioner Dave Jones said his investigation will focus on the appropriateness of Aetna’s practice and how widespread it was.  He said his expectation was that physicians were reviewing patients’ medical records.  He found it troubling that that was not happening.  “What I’m responding to is the portion of [Iinuma’s] deposition transcript in which he said as the medical director, he wasn’t actually reviewing medical records,” Jones told CNN.

 

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