A former medical director at Aetna admitted to denying and admitting cases without looking at records, encouraging an investigation from California’s insurance commissioner.
Dave Jones, the commissioner, was shown the medical director’s statement by CNN, which angered him to wonder how many other Aetna workers had done the same.
Jones expressed his frustration by saying, “If the health insurer is making decisions to deny coverage without a physician actually ever reviewing medical records, that’s of significant concern to me as insurance commissioner in California, and potentially a violation of law.”
Dr. Jay Ken Iinuma had been a medical director in Southern California, working at Aetna from March 2012 to February 2015. To defend himself, he claimed that he was simply following Aetna’s training and was given reviewed records and recommendations from nurses.
Jones stated, “It’s hard to imagine that in that entire course in time, there weren’t any cases in which a decision about the denial of coverage ought to have been made by someone trained as a physician, as opposed to some other licensed professional.”
He also commented that his expectation would be “that physicians would be reviewing treatment authorization requests and that it’s troubling that during the entire course of time he was employed at Aetna, he never once looked at patient’s medical records himself.”
Aetna is the nation’s third-largest insurance provider with around 23.1 billion customers and after hearing about the incident, it of course told CNN that it looked forward to “explaining our clinical review process” to Jones.
It went on by saying, “Aetna medical directors are trained to review all available medical information, including medical records, to make an informed decision. As part of our review process, medical directors are provided all submitted medical records, and also receive a case synopsis and review performed by a nurse.”
Gillen Washington is one of many affected by these practices and tried suing Aetna because he was denied coverage for an infusion of intravenous immunoglobulin (IVIG). He suffered from a rare immune disorder and claimed Aetna’s “reckless withholding of benefits almost killed him.”
Washington’s doctor said he never looked at a patient’s medical records and hadn’t even known how to treat Washington’s case. He also stated that most of his work was conducted online and he rarely called a nurse for more information.
As a patient, one would expect to be in good hands and have a reliable doctor. Billions of people trust Aetna and this news might sway some customers into being more wary. By siding with Iinuma, Aetna dug itself into a deeper hole.