Aetna slams 'gross misrepresentation' of clinical review process

Medical health records
Aetna says medical records are an "integral part" of how its medical directors determine whether to approve or deny treatment. (Image: Getty/nevarpp)

Aetna is hitting back against recent news coverage that cast doubt on its clinical review process and led state officials to launch investigations.

The firestorm started with a CNN article published on Sunday, which highlighted part of a deposition made by one of Aetna’s medical directors as part of a lawsuit that a patient filed against the insurer. In his deposition, Jay Ken Iinuma, M.D., said he never looked at patients' records when making decisions about whether approve or deny coverage.

In response, California Insurance Commissioner Dave Jones said he has launched an investigation into Aetna’s practices. In addition, Colorado Interim Insurance Commissioner Michael Conway said his office will contact the insurer “to inquire further” about its practices in that state.

Free Daily Newsletter

Like this story? Subscribe to FierceHealthcare!

The healthcare sector remains in flux as policy, regulation, technology and trends shape the market. FierceHealthcare subscribers rely on our suite of newsletters as their must-read source for the latest news, analysis and data impacting their world. Sign up today to get healthcare news and updates delivered to your inbox and read on the go.

Aetna, however, wrote in a lengthy response on its website that Iinuma’s deposition was “taken out of context to create media and courtroom leverage, and is a gross misrepresentation of how the process actually works.”

The insurer pointed to a sworn statement from Iinuma, dated Feb. 13, which “corrects certain misinterpretations” of his October testimony that were the subject of recent news coverage.

According to Iinuma, when he testified he never looked at a “medical record” while at Aetna, he meant the entirety of the historical file detailing a patient’s treatment and medical history. But he said he did review the portions of patients’ medical records provided to Aetna that were relevant to his coverage determinations—as well as nurses’ notes and other materials.

The bottom line, according to Aetna, is that “medical records were in fact an integral part of the clinical review process during Dr. Iinuma’s tenure at Aetna, consistent with his training.”

The insurer also pointed out that it has paid for every treatment received by the patient who is suing Aetna since he submitted his first claim as a member in 2014. That patient, Gillen Washington, has accused Aetna of denying him life-saving infusions, but Aetna contends that the only interruption in Washington’s treatment “was the result of the individual defying his doctor’s orders and refusing to provide necessary bloodwork.”

It’s unclear whether Aetna’s rebuttal will affect any current or future investigations on the part of state officials. But either way, the controversy surrounding Iinuma’s testimony is likely to impact the health insurance industry’s reputation, Kaiser Family Foundation Senior Vice President Larry Levitt told Vox.

“This is the kind of story that feeds cynicism about insurers among patients,” he said.