California launches Aetna probe after incendiary testimony by insurer's former SoCal medical director

por Thomas Dworetzky, Contributing Reporter | February 13, 2018
Business Affairs Insurance
Aetna's former Southern California medical director has admitted under oath that he didn't examine patients' records when determining whether to okay coverage, according to a CNN report.

When the network presented the transcript of the testimony to California Insurance Commissioner Dave Jones, it so alarmed him that he has now launched an investigation.

"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," said Jones.

The insurer told the network that it was eager to explain “our clinical review process" to authorities.

The probe concerns a deposition by the Aetna medical director for Southern California from March, 2012, to February, 2015, Dr. Jay Ken Iinuma.

According to the testimony, the physicians said that he followed Aetna's training and had nurses review records and recommend action to him.

"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," Jones told CNN.

"That's why we've contacted Aetna and asked that they provide us information about how they are making these claims decisions and why we've opened this investigation."

The commissioner has called on all Californians who might have been negatively impacted by the Aetna process to reach out to his office.

The California situation has led other health care professionals nationwide to raise the alarm about possible Aetna practices.

Dr. Andrew Murphy, a fellow of the American Academy of Allergy and Immunology told the network that "this is potentially a huge, huge story and quite frankly may reshape how insurance functions."

"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," he told the network, adding that, "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."

The former Aetna medical director's testimony came during a lawsuit filed by Gillen Washington, 23, who is suing the insurer for breach of contract and bad faith, saying he was denied coverage for an infusion of intravenous immunoglobulin (IVIG) when he was 19. His suit alleges Aetna's "reckless withholding of benefits almost killed him."

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