Aetna Director Regularly Denied Claims Without Even Reading Them

Former Aetna medical director Dr. Jay Ken Iinuma.Screengrab/CNN/YouTube

The former medical director testified that he never at medical records himself before approving or denying treatments.

A former medical director for Aetna's southern California region admitted under oath that he did not examine patient's medical records when determining whether to approve or deny treatment. Upon being informed of the situation, California's insurance commissioner has launched an investigation.

California Insurance Commissioner Dave Jones expressed outrage after CNN showed him a transcript of the testimony and said his office is looking into how widespread the practice is within Aetna.

"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.

Aetna told CNN it looks forward to "explaining our clinical review process" to California's commissioner.

The California probe centers on a deposition by Dr. Jay Ken Iinuma, who served as medical director for Aetna for Southern California from March 2012 to February 2015, according to the insurer.

Iinuma said during the deposition that he simply followed company procedure, which involved nurses reviewing records and making recommendations. At no time did he review medical records himself.

Jones said 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 patients' medical records himself."

"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.

Numerous medical professionals expressed surprise and outrage that a medical director would not check records before reaching a decision:

"Oh my God. Are you serious? That is incredible," said Dr. Anne-Marie Irani when told of the medical director's testimony. Irani is a professor of pediatrics and internal medicine at the Children's Hospital of Richmond at VCU and a former member of the American Board of Allergy and Immunology's board of directors.

"This is potentially a huge, huge story and quite frankly may reshape how insurance functions," said Dr. Andrew Murphy, who, like Irani, is a renowned fellow of the American Academy of Allergy, Asthma and Immunology. He recently served on the academy's board of directors.
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Dr. Arthur Caplan, founding director of the division of medical ethics at New York University Langone Medical Center, described Iinuma's testimony as "a huge admission of fundamental immorality."

"People desperate for care expect at least a fair review by the payer. This reeks of indifference to patients," Caplan said, adding the testimony shows there "needs to be more transparency and accountability" from private, for-profit insurers in making these decisions.

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