Aetna is facing backlash—and an investigation in California—after a former medical director testified that he never looked at patients’ medical records when making coverage decisions.
Jay Ken Iinuma, M.D., made that admission during a deposition tied to a lawsuit filed against Aetna by a college student with a rare immune disorder, CNN reported. Gillen Washington accused Aetna of denying him life-saving infusions, but Aetna contended that he failed to comply with their requests for blood work and later, once his coverage was preauthorized, continued to miss infusions.
But it’s not the case itself that is stirring up the biggest controversy—it’s what Iinuma, who was Aetna’s medical director for Southern California from 2012 to 2015, said when questioned about how the insurer determines what to cover.
Iinuma said he never looked at a patient’s medical records when employed by Aetna, instead basing his coverage decisions on information provided to him by nurses, per CNN. He also said that was protocol at the company and that most of his decisions were conducted online, with a rare call to a nurse to ask for more details.
That admission caught the attention of California Insurance Commissioner Dave Jones, who told CNN he now will review every denial of coverage or preauthorization during Iinuma’s tenure.
"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," Jones said.
Other experts were also alarmed by Iinuma’s testimony. Arthur Caplan, M.D., founding director of the division of medical ethics at New York University Langone Medical Center, told CNN that “this reeks of indifference to patients.”