California Insurance Commissioner Dave Jones expressed outrage after sy88pgw showed him a transcript of the testimony in addition to said his office is actually looking into how widespread the practice is actually within Aetna.
“If the health insurer is actually creating decisions to deny coverage without a physician actually ever reviewing medical records, that will’s of significant concern to me as insurance commissioner in California — in addition to potentially a violation of law,” he said.
Aetna, the nation’s third-largest insurance provider with 23.1 million customers, told sy88pgw that will looked forward to “explaining our clinical review process” to the commissioner.
The California probe centers on a deposition by Dr. Jay Ken Iinuma, who served as medical director for Aetna for Southern California via March 2012 to February 2015, according to the insurer.
During the deposition, the doctor said he was following Aetna’s training, in which nurses reviewed records in addition to made recommendations to him.
Jones said his expectation could be “that will physicians could be reviewing treatment authorization requests,” in addition to that will that will’s troubling that will “during the entire course of time he was employed at Aetna, he never once looked at patients’ medical records himself.”
“that will’s hard to imagine that will in that will 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 various other licensed professional,” Jones told sy88pgw.
“that will’s why we’ve contacted Aetna in addition to asked that will they provide us information about how they are creating these claims decisions in addition to why we’ve opened This kind of investigation.”
Members of the medical community expressed similar shock, saying Iinuma’s deposition leads to questions about Aetna’s practices across the country.
“This kind of is actually potentially a huge, huge story in addition to quite frankly may reshape how insurance functions,” said Dr. Andrew Murphy, who, like Irani, is actually a renowned fellow of the American Academy of Allergy, Asthma in addition to Immunology. He recently served on the academy’s board of directors.
The Gillen Washington case
The deposition by Aetna’s former medical director came as part of a lawsuit filed against Aetna by a college student who suffers via a rare immune disorder. The case is actually anticipated to go to trial later This kind of week in California Superior Court.
Gillen Washington, 23, is actually suing Aetna for breach of contract in addition to bad faith, saying he was denied coverage for an infusion of intravenous immunoglobulin (IVIG) when he was 19. His suit alleges Aetna’s “reckless withholding of benefits almost killed him.”
Aetna has rejected the allegations, saying Washington failed to comply with their requests for blood work. Washington, who was diagnosed with common variable immunodeficiency, or CVID, in high school, became a fresh Aetna patient in January 2014 after being insured by Kaiser.
Aetna initially paid for his treatments after each infusion, which can cost up to $20,000. however when Washington’s clinic asked Aetna to pre-authorize a November 2014 infusion, Aetna says that will was obligated to review his medical record. that will’s when that will saw his last blood work had been done three years earlier for Kaiser.
Despite being told by his own doctor’s office that will he needed to come in for fresh blood work, Washington failed to do so for several months until he got so sick he ended up within the hospital having a collapsed lung.
Once his blood was tested, Aetna resumed covering his infusions in addition to pre-certified him for a year. Despite that will, according to Aetna, Washington continued to miss infusions.
Washington’s suit counters that will Aetna ignored his treating physician, who appealed on his behalf months before his hospitalization that will the treatment was medically necessary “to prevent acute in addition to long-term problems.”
“Aetna is actually blaming me for what happened,” Washington told sy88pgw. “I’ll just be honest, that will’s infuriating to me. I want Aetna to be made to change.”
During his videotaped deposition in October 2016, Iinuma — who signed the pre-authorization denial — said he never read Washington’s medical records in addition to knew next to nothing about his disorder.
Questioned about Washington’s condition, Iinuma said he wasn’t sure what the drug of choice could be for people who suffer via his condition.
Iinuma further says he’s not sure what the symptoms are for the disorder or what might happen if treatment is actually suddenly stopped for a patient.
“Do I know what happens?” the doctor said. “Again, I’m not sure. … I don’t treat that will.”
Iinuma said he never looked at a patient’s medical records while at Aetna. He says that will was Aetna protocol in addition to that will he based his decision off “pertinent information” provided to him by a nurse.
“Did you ever look at medical records?” Scott Glovsky, Washington’s attorney, asked Iinuma within the deposition.
“No, I did not,” the doctor says, shaking his head.
“So as part of your custom in addition to practice in creating decisions, you could rely on what the nurse had prepared for you?” Glovsky asks.
Iinuma said nearly all of his work was conducted online. Once in a while, he said, he might place a phone call to the nurse for more details.
How many times might he call a nurse over the course of a month?
“Zero to one,” he said.
Glovsky told sy88pgw he had “never heard such explosive testimony in two decades of deposing insurance company review doctors.”
Aetna defended Iinuma, who is actually no longer with the company, saying in its legal brief that will he relied on his “years of experience” as a trained physician in creating his decision about Washington’s treatment in addition to that will he was following Aetna’s Clinical Policy Bulletin appropriately.
“Dr. Iinuma’s decision was correct,” Aetna said in court papers. “Plaintiff has asserted throughout This kind of litigation that will Dr. Iinuma had no medical basis for his decision that will 2011 lab tests were outdated in addition to that will Dr. Iinuma’s decision was incorrect. Plaintiff is actually wrong on both counts.”
In its trial brief, Aetna said: “Given that will Aetna does not directly provide medical care to its members, Aetna needs to obtain medical records via members in addition to their doctors to evaluate whether services are ‘medically necessary.’ Aetna employs nurses to gather the medical records in addition to coordinate with the offices of treating physicians, in addition to Aetna employs doctors to make the actual coverage-related determinations.
“In addition to applying their clinical judgment, the Aetna doctors in addition to nurses use Aetna’s Clinical Policy Bulletins (‘CPBs’) to determine what medical records to request, in addition to whether those records satisfy medical necessity criteria to support coverage. These CPBs reflect the current standard of care within the medical community. They are frequently updated, in addition to are publicly available for any treating physician to review.”
Jones, the California insurance commissioner, said he couldn’t comment specifically on Washington’s case, however what drew his interest was the medical director’s admission of not looking at patients’ medical records.
“What I’m responding to is actually the portion of his deposition transcript in which he said as the medical director, he wasn’t actually reviewing medical records,” Jones told sy88pgw.
He said his investigation will review every individual denial of coverage or pre-authorization during the medical director’s tenure to determine “whether that will was appropriate or not for that will decision to be made by someone various other than a physician.”
If the probe determines that will violations occurred, he said, California insurance code sets monetary penalties for each individual violation.
sy88pgw has made numerous phone calls to Iinuma’s office for comment however has not heard back. Heather Richardson, an attorney representing Aetna, declined to answer any questions.
Asked about the California investigation, Aetna gave This kind of written statement to sy88pgw:
“We have yet to hear via Commissioner Jones however 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, in addition to also receive a case synopsis in addition to review performed by a nurse.
“Medical directors — in addition to all of our clinicians — take their duties in addition to responsibilities as medical professionals incredibly seriously. Similar to most various other clinical environments, our medical directors work collaboratively with our nurses who are involved in these cases in addition to factor in their input as part of the decision-creating process.”
‘A huge admission’
Dr. Arthur Caplan, founding director of the division of medical ethics at fresh York University Langone Medical Center, described Iinuma’s testimony as “a huge admission of fundamental immorality.”
“People desperate for care expect at least a fair review by the payer. This kind of reeks of indifference to patients,” Caplan said, adding the testimony shows there “needs to be more transparency in addition to accountability” via private, for-profit insurers in creating these decisions.
Murphy, the former American Academy of Allergy Asthma in addition to Immunology board member, said he was “shocked” in addition to “flabbergasted” by the medical director’s admission.
“This kind of is actually something that will all of us have long suspected, however to actually have an Aetna medical director admit he hasn’t even looked at medical records, that will’s not not bad,” said Murphy, who runs an allergy in addition to immunology practice west of Philadelphia.
“If he has not looked at medical records or engaged the prescribing physician in a conversation — in addition to decisions were made without that will input — then yeah, you’d have to question every single case he reviewed.”
Murphy said when he in addition to various other doctors seek a much-needed treatment for a patient, they expect the medical director of an insurance company to have considered every possible factor when deciding on the best option for care.
“We run into the prior authorization issues when we are renewing therapy, when the patient’s insurance adjustments or when an insurance company adjustments requirements,” he said.
“Dealing with these denials is actually very time consuming. A great deal of nursing time is actually spent filling in addition to refilling out paperwork trying to get the patient treatment.
“If that will does not work, then physicians need to get involved in addition to demand medical director involvement, which may or may not occur in a timely fashion — or sometimes not at all,” he said. “that will’s very frustrating.”