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Aetna Under Investigation After Doctor Responsible for Denying Claims Admits He Never Looked at Patients' Records

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Aetna is under investigation after a former Aetna medical director admitted during a deposition that he never looked at patients’ records when he had to deny or approve coverage.

The investigation was launched by California Insurance Commissioner Dave Jones, who learned of the former director’s admission when CNN showed him a transcript of the deposition.

Dr. Jay Ken Iinuma was the medical director for Aetna for Southern California from March 2012 to February 2015. In 2016, he gave a deposition as part of a lawsuit against Aetna filed by Gillen Washington, a college student with common variable immune deficiency (CVID). Washington is suing Aetna for breach of contract and bad faith and claims Aetna’s “reckless withholding of benefits almost killed him.” Aetna claims Washington failed to comply with their requests for blood work, a condition of their coverage. Washington’s case is expected to go to trial in California Superior Court this week.

Iinuma signed a denial for a pre-authorization for an infusion Washington requested. But during his deposition, he admitted that he never looked at Washington’s, or other patients’ medical records, and didn’t know the symptoms of Washington’s disorder, the drugs required for his condition or what would happen if treatment was stopped.

“Do I know what happens?” Iinuma said. “Again, I’m not sure… I don’t treat it.”

He said he based his decision on “pertinent information” given by a nurse, following Aetna’s training. He said most of his work was conducted online and he might call a nurse for more information “zero to one” time in a month.

CNN provided a transcript of Iinuma’s statements:

“Did you ever look at medical records?” said Scott Glovsky, Washington’s attorney.
“No, I did not,” said Iinuma.
“So as part of your custom and practice in making decisions, you would rely on what the nurse had prepared for you?” Glovsky asked.
“Correct,” Iinuma said.

Jones told CNN that he couldn’t comment on the specifics of Washington’s case, but that he was responding to the portion of the deposition in which Iinuma said as the medical director, he wasn’t actually reviewing medical records. The investigation will look at every denial of coverage or pre-authorization during Iinuma’s time as medical director at Aetna and determine whether or not it was appropriate for that decision to be made by someone other than a physician.

“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,” he said.

In a statement to CNN, Aetna said it “look[s] forward to explaining our clinical review process.”

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.

Medical directors — and all of our clinicians — take their duties and responsibilities as medical professionals incredibly seriously. Similar to most other clinical environments, our medical directors work collaboratively with our nurses who are involved in these cases and factor in their input as part of the decision-making process.

According to Jones, if their investigation finds that violations did occur, California insurance code sets monetary penalties for each violation.

“The department is seeking more information from Aetna about their claims denial process and I would encourage any Californians who are concerned that they might have been affected to contact the California Department of Insurance at 1-800-927-4357,” Jones added in a statement to The Mighty.

Lead photo courtesy of Montgomery County Planning Commission via Flickr

Originally published: February 13, 2018
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