The state of California has launched an investigation into Aetna after one of the insurer's former medical directors said he did not personally review patients' medical records when deciding to approve or deny claims, opting instead to rely on the recommendations of nurses.
According to CNN, Jay Ken Iinuma, who worked as Aetna's medical director for Southern California between March 2012 to February 2015, made the comments as part of a 2016 deposition. In the deposition, Iinuma said per company protocol, he based his coverage approval decisions off of the "pertinent information" provided to him by a nurse. He said he would occasionally call a nurse for further details about a patient, but that he never personally looked at patients' records.
The deposition was conducted as part of lawsuit filed against Aetna by Gillen Washington, a 23-year-old who suffers from common variable immunodeficiency. In the lawsuit, Washington alleged that Aetna denied him coverage of intravenous immunoglobulin (IVIG) when he was 19-years-old, saying that the insurer's "reckless withholding of benefits almost killed him." Aetna has pushed back against the allegations, saying that Washington had failed to provide blood work the insurer had requested and frequently failed to show up for IVIG infusions.
According to CNN, Aetna in court papers defended Iinuma, who had signed off on Washington's pre-authorization denial. The insurer stated, "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." According to the insurer, doctors and nurses rely on Aetna's Clinical Policy Bulletins "to determine what medical records to request, and whether those records satisfy medical necessity criteria to support coverage."
The lawsuit is scheduled to go to trial later this week in state Superior Court, CNN reports.
A shocked reaction and an investigation
California Insurance Commissioner Dave Jones (D) expressed shock at Iinuma's comments, saying that he would expect "physicians would be reviewing treatment authorization requests," and his office this week launched an investigation into the insurer's practices.
In a statement, Jones said, "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 added, "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."
According to Jones, the investigation will examine every denial or pre-authorization made during Ilinuma's time as medical director to determine "whether it was appropriate or not for that decision to be made by someone other than a physician." If his office does determine there was a violation, monetary penalties will be levied against Aetna, per California's insurance code, CNN reports.
Jones added that state residents who believe they might have been adversely affected by how Aetna made its coverage decisions should get in touch with his office. According to CNN, Jones said he could not provide specific comment on Washington's lawsuit.
Several medical professionals have voiced surprise at Iinuma's comments, CNN reports.
Arthur Caplan, founding director of the division of medical ethics at New York University Langone Medical Center, called Iinuma's testimony "a huge admission of fundamental immorality." He added, "People desperate for care expect at least a fair review by the payer. This reeks of indifference to patients." He said the comments show that there "needs to be more transparency and accountability" from private, for-profit insurers regarding their coverage decisions.
Separately, Andrew Murphy, a former board member of the American Academy of Allergy Asthma and Immunology, said he was "shocked" and "flabbergasted" by the comments. "This is something that all of us have long suspected, but to actually have an Aetna medical director admit he hasn't even looked at medical records, that's not good," Murphy, who now runs a private practice in Philadelphia, said. "If he has not looked at medical records or engaged the prescribing physician in a conversation—and decisions were made without that input—then yeah, you'd have to question every single case he reviewed."
Aetna responded to the investigation in a written statement given to CNN. "Medical directors—and all of our clinicians—take their duties and responsibilities as medical professionals incredibly seriously," the insurer said. "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" (Baker, "Vitals," Axios, 2/12; Drash, CNN, 2/11).