Aetna faces probe over former medical director's testimony

Health insurance, pen and stethoscope
Aetna is under fire over its processes for determining whether it will approve or deny coverage for treatments or services.
(Image: Getty/Minerva Studio)

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.

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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.”

For Aetna's part, the insurer said in a statement to FierceHealthcare that its medical directors "review all necessary available medical information for cases that they are asked to evaluate," and noted that "adherence to those guidelines, which are based on health outcomes and not financial considerations, is an integral part of their yearly review process."
 
"While we can’t comment on the alleged actions of a former employee due to ongoing litigation, we want to be clear that our policies always have our members’ best interests in mind," the company added.
 
Aetna is not the only major insurer to come under fire recently over how it approves and denies coverage. Various healthcare provider groups have been criticizing Anthem over the insurer’s policies for covering emergency room visits, outpatient imaging services and most recently, anesthesia during cataract surgery.
 
Editor's note: This article has been updated to include an updated statement from Aetna.