Top Senate Democrats are demanding answers from Aetna CEO Mark Bertolini after a former medical director for the insurer said he didn't read patients' medical records when making coverage decisions.
Sens. Ron Wyden, of Oregon, the ranking member of the Senate Finance Committee, and Patty Murray, of Washington, wrote a letter (PDF) to Bertolini last week, saying that Jay Ken Iinuma's testimony raises serious questions about Aetna's claims review process.
Iinuma, M.D., served as Aetna's medical director of Southern California from 2012 to 2015. He said he didn't look at patients' records for coverage decisions, instead relying on information provided to him by nurses. He said this was standard procedure at the company.
Iinuma testified as part of a deposition tied to a lawsuit filed against Aetna by a patient with a rare immune disorder, who said the insurer denied him life-saving blood infusions. Iinuma's testimony launched an investigation by the California Department of Insurance.
Aetna said that Iinuma's testimony was taken out of context, leading to a "gross misrepresentation" of how the insurer's claims process works.
Wyden and Murray said in the letter that the case raises concerns about the adequacy of Aetna's policies, and if they comply with federal law, as it would skirt consumer safeguards included in the Affordable Care Act. The senators requested the Bertolini provide a more detailed description of Aetna's coverage determination protocols, and records of claim reviews made by medical directors over the past five years.
The senators said they requested a full copy of Iinuma's testimony from the attorney for the patient in the case but were denied because of confidentiality claims from Aetna, and are requesting his deposition in full from the insurer as well.
No patient should be wrongly denied coverage for care they need just because their insurance provider couldn’t bother to carefully review a claim. https://t.co/Jl6PcstUZL— Senator Patty Murray (@PattyMurray) March 1, 2018
Murray said in an announcement (PDF) that a patient receiving a coverage denial in the manner Iinuma described is "completely unacceptable."
"Using medical records is a fundamental responsibility of health insurers when they review health claims," Wyden said. "Something is gravely wrong if a leading insurance company is failing to use this basic information at the expense of families' health and peace of mind."
The senators requested that Bertolini answer their questions by March 20. Aetna told CNN that it will comply with the deadline.