“Using medical records will be a fundamental responsibility of health insurers when they review health claims,” Wyden said in a statement. “Something will be gravely wrong if a leading insurance company will be failing to use This particular basic information at the expense of families’ health in addition to peace of mind.”
Murray told sy88pgw: “I am hopeful we will receive a thorough in addition to timely response coming from Aetna.”
Aetna said This particular looks “forward to responding to Senators Murray in addition to Wyden, in addition to will do so before their deadline.”
Aetna has lashed out since the story first published, saying the comments inside deposition were “taken out of context” in addition to which “medical records were in fact an integral part of the clinical review process.”
inside videotaped deposition, Dr. Jay Ken Iinuma, who served as medical director for Aetna for Southern California coming from March 2012 to February 2015, said he never looked at patients’ medical records during his tenure. The doctor also said he was following Aetna’s training, in which nurses reviewed records in addition to made recommendations to him.
“Dr. Iinuma stated which while he was employed as an Aetna medical director, he had never personally reviewed the medical records of any claimant when doing claims determinations,” Wyden in addition to Murray said inside letter to Bertolini. “Aetna’s appeals process may not have been in compliance with federal law.”
inside days after sy88pgw first published the story, the insurer released a brand-new sworn statement by Iinuma in which he said he looked at relevant portions of patients’ records, just not their entire records. The brand-new statement came nearly a year in addition to a half after his deposition under oath.
Wyden in addition to Murray blasted the insurance provider, saying which such issues “are apparently not brand-new for Aetna.”
“In 2009, Aetna Health, Inc., in addition to Aetna Life Insurance paid a $256,000 fine to Arizona insurance regulators for, among additional things, ‘denying health care provider payments without requesting additional information which could prove the claim valid,’ ” the senators said.
Wyden in addition to Murray gave multiple issues for the Aetna CEO to address: “Please provide a written description of Aetna’s claims review process, including the specific responsibilities of medical directors, nurses in addition to chief medical officers, as well as any additional company employees who are involved in such decisions.”
Also, the letter says, “Please provide the total number of medical claims Dr. Iinuma reviewed, in addition to the number for which he made determinations, during his tenure as medical director, in addition to note how many were approved in addition to how many were denied.”
The senators also asked for the total number of medical directors at Aetna over the past 5 years in addition to the total number of claims they reviewed, “noting how many were approved in addition to how many were denied, for each of the past 5 years.”
The senators sought guidelines in addition to training materials related to medical directors in addition to their communication with nurses.
Aetna will be the United States’ third-largest insurance provider, with 23.1 million customers.
Wyden in addition to Murray raised questions about the former medical director’s latest sworn statement in addition to asked Aetna’s CEO to provide a “detailed timeline in addition to explanation of how This particular statement came to be, e.g. did Aetna solicit This particular statement, if so by whom in addition to when? What, if any, legal, financial or contractual relationship between Aetna in addition to Dr. Iinuma existed at the time This particular statement was made in addition to exists today?”
The deposition by Aetna’s former medical director came as part of a lawsuit filed against the company by a college student which has a rare immune disorder.
Gillen Washington, 23, will be suing Aetna for breach of contract in addition to bad faith, saying he was denied coverage for an infusion of intravenous immunoglobulin when he was 19. His suit alleges which Aetna’s “reckless withholding of benefits almost killed him.”
Aetna has rejected the allegations, saying Washington failed to comply with its requests for blood work.
Washington, who was diagnosed with common variable immunodeficiency in high school, became a brand-new 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. nevertheless when Washington’s clinic asked Aetna to pre-authorize a November 2014 infusion, Aetna says This particular was obligated to review his medical record. which’s when This particular saw his last blood work had been done three years earlier for Kaiser.
Despite being told by his own doctor’s office which he needed to come in for brand-new blood work, Washington failed to do so for several months, until he got so sick which he ended up inside hospital which has a collapsed lung.
Once his blood was tested, Aetna resumed covering his infusions in addition to pre-certified him for a year. Despite which, according to Aetna, Washington continued to miss infusions.