The California insurance commissioner has begun an investigation of health insurer Aetna after a former medical director for the company admitted under oath that he never looked at patients' records in determining whether to approve or deny care.
CNN reports that after reviewing a deposition from Dr. Jay Ken Iinuma, who served as medical director for Aetna for Southern California from March 2012 to February 2015, California insurance commissioner Dave Jones expressed "outrage" at the idea that coverage was being denied without a physician reviewing patient records.
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In the report, Jones says, "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 adds that his office's investigation is looking into how widespread the practice is within Aetna.
In his deposition, the doctor said he was following Aetna's training, in which nurses reviewed records and made recommendations to him. According to the report, Aetna has said that it looks forward to "explaining our clinical review process" to the commissioner.
The deposition came about as part of a lawsuit filed against Aetna by a college student who suffers from a rare immune disorder; the student is represented by the law firm of Scott Glovsky. The trial is expected to begin in California Superior Court later this week. Aetna has defended Iinuma, saying in its legal brief that he relied on his "years of experience" as a trained physician in making his decision about the plaintiff's treatment and that he was following Aetna's Clinical Policy Bulletin appropriately.
Jones also says that 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 [Iinuma] was employed at Aetna, he never once looked at patients' medical records himself."
He adds, "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. That's why we've contacted Aetna and asked that they provide us information about how they are making these claims decisions and why we've opened this investigation."
Members of the medical community have expressed concern, according to the report, not only that this was the procedure Iinuma followed, but also about how Aetna's practices elsewhere across the country are conducted.
Jones has also said Californians who believe they may have been adversely affected by Aetna's decisions should contact his office.
CNN received the following written statement from Aetna in response to questions about the California investigation:
"We have yet to hear from Commissioner Jones but look forward to explaining our clinical review process.
"Aetna medical directors are trained to review all available medical information—including medical records—to make an informed decision. As part of our review process, medical directors are provided all submitted medical records, and also receive a case synopsis and review performed by a nurse.
"Medical directors—and all of our clinicians—take their duties and responsibilities as medical professionals incredibly seriously. Similar to most other clinical environments, our medical directors work collaboratively with our nurses who are involved in these cases and factor in their input as part of the decision-making process."
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