It’s not turning out to be a great month for Aetna. Last week launched the beginning of a legal battle between the health insurer and Kurtzman Carson Consultants over a mailing that accidentally disclosed the HIV statuses of up to 12,000 members.
Now, California insurance commissioner Dave Jones has started an investigation into Aetna after its former medical director said under oath that he never looked at patients’ medical records when deciding whether to deny or approve care, reports CNN.
The comments made by Dr. Jay Ken Iinuma were part of a deposition in a lawsuit brought against the Hartford, Connecticut-based insurer by 23-year-old Gillen Washington. He suffers from common variable immunodeficiency (or CVID) and said Aetna denied him coverage for an infusion of intravenous immunoglobulin when he was 19. For its part, Aetna denied the allegations and said Washington didn’t fulfill its requests for blood work.
The suit is anticipated to go to trial in California Superior Court.
In Iinuma’s videotaped October 2016 deposition, he said he didn’t know much about CVID, proper drug treatment or what might happen if treatment is suddenly halted.
“Do I know what happens?” Iinuma said, according to CNN. “Again, I’m not sure … I don’t treat it.”
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
He went on to admit he never looked at patients’ records at Aetna and instead relied on information provided by a nurse. Most of his work, he said, was found online. During any given month, Iinuma said he’d call a nurse “zero to one” times to gather more data.
Iinuma held the medical director role from 2012 to February 2015, according to CNN.
Commissioner Jones told CNN his investigation will focus on a review of each denial of coverage during Iinuma’s tenure in an attempt to decide whether it was suitable for the decision “to be made by someone other than a physician.”
“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, according to CNN.
Aetna sent the following statement via email:
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.
Dr. Iinuma’s tenure with Aetna ended in 2015.
In a phone interview, Dr. Pedram Hendizadeh, a podiatrist and the founder and CEO of UMA Health, commented on the situation.
“It’s obviously infuriating to have a doctor in that position who’s not really looking at medical records,” he said. “It’s very dangerous to leave medical decisions to a party who has no firsthand knowledge of the patient. Unfortunately, insurance companies in the United States are fundamentally flawed in my opinion.”
He said insurers are focused on increasing their own profits, and that many of the denials they make aren’t warranted.
Hendizadeh added that some of his peers have had to embellish a patient’s symptoms to ensure the insurance company will cover the claim.
“In the medical world, this is not a surprise,” he said.
Photo: utah778, Getty Images
