CNN Exclusive: California launches investigation following stunning admission by Aetna medical director
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California’s insurance commissioner has launched an investigation into Aetna after learning a former medical director for the insurer admitted under oath he never looked at patients’ records when deciding whether to approve or deny care.
California Insurance Commissioner Dave Jones expressed outrage after CNN showed him a transcript of the testimony and said his office is looking into how widespread the practice is within Aetna.
“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 said.
Aetna, the nation’s third-largest insurance provider with 23.1 million customers, told CNN it looked forward to “explaining our clinical review process” to the commissioner.
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The deposition by Aetna’s former medical director came as part of a lawsuit filed against Aetna by a college student who suffers from a rare immune disorder. The case is expected to go to trial later this week in California Superior Court.
Gillen Washington, 23, is suing Aetna for breach of contract and 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 new Aetna patient in January 2014 after being insured by Kaiser.
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During his videotaped deposition in October 2016, Iinuma — who signed the pre-authorization denial — said he never read Washington’s medical records and knew next to nothing about his disorder.
Questioned about Washington’s condition, Iinuma said he wasn’t sure what the drug of choice would be for people who suffer from his condition.
Iinuma further says he’s not sure what the symptoms are for the disorder or what might happen if treatment is suddenly stopped for a patient. “Do I know what happens?” the doctor said. “Again, I’m not sure. … I don’t treat it.”
Iinuma said he never looked at a patient’s medical records while at Aetna. He says that was Aetna protocol and that he based his decision off “pertinent information” provided to him by a nurse.
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Jones, the California insurance commissioner, said he couldn’t comment specifically on Washington’s case, but what drew his interest was the medical director’s admission of not looking at patients’ medical records.
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Dr. Arthur Caplan, founding director of the division of medical ethics at New 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 reeks of indifference to patients,” Caplan said, adding the testimony shows there “needs to be more transparency and accountability” from private, for-profit insurers in making these decisions.
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“Dealing with these denials is very time consuming. A great deal of nursing time is spent filling and refilling out paperwork trying to get the patient treatment.
“If that does not work, then physicians need to get involved and demand medical director involvement, which may or may not occur in a timely fashion — or sometimes not at all,” [said Dr. Andrew Murphy, a renowned fellow of the American Academy of Allergy, Asthma and Immunology.] “It’s very frustrating.”
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