A former Aetna medical director has admitted to not looking at patients' records when deciding whether to approve or deny care, according to an exclusive investigation by CNN.
The CNN report stated that Dr. Jay Ken Iinuma, who served as medical director for Aetna for southern California from 2012 to 2015, and the insurer, are being investigated by the California's insurance commissioner after Iinuma admitted under oath in a 2016 deposition that he never read the medical records of a patient with a rare immune disorder and “knew next to nothing about his disorder.”
The case in question involves Gillen Washington, 23, who is suing Aetna for breach of contract and bad faith, saying he was denied coverage for an infusion of intravenous immunoglobulin (IVIG) when he was 19, according to CNN. The lawsuit alleges Aetna's "reckless withholding of benefits almost killed him." The case is expected to go to trial later this week in California Superior Court. CNN reported that Aetna has rejected the allegations, countering that Washington failed to comply with their requests for blood work. Scott Glovsky, a health insurance denials attorney with the Law Offices of Scott Glovsky is representing the plaintiff.
Aetna, which initially paid for Washington’s treatments after each infusion, didn’t pre-authorize a November 2014 infusion because it needed current blood work to meet the criteria. But despite being told by his own doctor that he needed to come in for the blood work, Washington failed to do so for several months. Once his blood was tested, Aetna resumed covering his infusions, the insurer said. But without the treatment, Washington became very sick and ended up in the hospital with a collapsed lung. The patient’s lawsuit, on the other hand, says that Aetna ignored his treating physician who said that the treatment was medically necessary, as reported by CNN.
Meanwhile, during the 2016 deposition, Iinuma said he wasn't sure what the drug of choice would be for people who suffer from his condition, while adding that said he “never looked at a patient's medical records while at Aetna.” He said that was the Aetna protocol and that he based his decision off "pertinent information" provided to him by a nurse, according to the report.
The Hartford, Conn.-based Aetna, the nation's third-largest insurance provider with 23.1 million customers, told CNN that it looked forward to "explaining our clinical review process" to California Insurance Commissioner Dave Jones. Said Jones, per the report, “"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."
In a legal brief, Aetna alleged that Iinuma relied on his "years of experience" as a trained physician in making his decision about Washington's treatment and that he was following the insurer’s policy protocols. Aetna further stated in the brief, “"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.”
To this point, the California Nurses Association/National Nurses United released a statement about this case that said it “highlights a widespread abuse in the insurance industry that can have catastrophic consequences for patients.” The Association added the case is not an isolated incident and that research has found that 60 to 80 percent of health insurance denials are reversed by independent medical review by the California Department of Managed Health Care.
If it is determined that violations have occurred, California insurance code sets monetary penalties for each individual violation, according to CNN.