(CNN) California’s insurance commissioner has launched a study into Aetna after learning an ex medical director for the insurer accepted under oath he never checked out patients’ records when deciding regardless of whether to approve or deny treatment.
“If the health insurer is making choices to deny coverage without a doctor actually ever reviewing medical information, that’s of significant concern in my opinion as insurance commissioner in Ca — and potentially a infringement of law, ” he stated.
Aetna, the country’s third-largest insurance provider with 23. one million customers, told CNN this looked forward to “explaining our clinical evaluation process” to the commissioner.
The California probe facilities on a deposition by Dr . The writer Ken Iinuma, who served since medical director for Aetna designed for Southern California from March this year to February 2015, according to the insurance provider.
During the deposition, the doctor said he or she was following Aetna’s training, by which nurses reviewed records and produced recommendations to him.
Jones said their expectation would be “that physicians will be reviewing treatment authorization requests, inch and that it’s troubling that “during the entire course of time he has been employed at Aetna, he in no way once looked at patients’ medical information himself. ”
“It’s hard to imagine that because entire course in time, there were unable any cases in which a decision in regards to the denial of coverage ought to have already been made by someone trained as a doctor, as opposed to some other licensed professional, inch Jones told CNN.
“That’s why we now have contacted Aetna and asked which they provide us information about how they make these claims decisions and precisely why we’ve opened this investigation. inch
The insurance office said Californians who believe they might have been adversely affected by Aetna’s choices should contact his office
Members of the healthcare community expressed similar shock, stating Iinuma’s deposition leads to questions regarding Aetna’s practices across the country.
“Oh my God. Have you been serious? That is incredible, ” mentioned Dr . Anne-Marie Irani when informed of the medical director’s testimony. Irani is a professor of pediatrics plus internal medicine at the Children’s Hospital associated with Richmond at VCU
and a former member of the United states Board of Allergy and Immunology’s board of directors.
“This is potentially an enormous, huge story and quite frankly might reshape how insurance functions, inch said Dr . Andrew Murphy, who seem to, like Irani, is a renowned other of the American Academy of Allergic reaction, Asthma and Immunology. He lately served on the academy’s board associated with directors.
The Gillen Washington case
The particular deposition by Aetna’s former healthcare director came as part of a lawsuit submitted against Aetna by a college student which suffers from a rare immune disorder. The situation is expected to go to trial afterwards this week in California Superior Courtroom.
Gillen Washington, 23, is suing Aetna for breach of contract plus bad faith, saying he had been denied coverage for an infusion associated with intravenous immunoglobulin (IVIG) when he or she was 19. His suit claims Aetna’s “reckless withholding of advantages almost killed him. ”
Aetna has turned down the allegations, saying Washington did not comply with their requests for bloodstream work. Washington, who was diagnosed with typical variable immunodeficiency, or CVID, within high school, became a new Aetna affected person in January 2014 after becoming insured by Kaiser.
Aetna initially covered his treatments after each infusion, which can cost up to $20, 1000. But when Washington’s clinic asked Aetna to pre-authorize a November 2014 infusion, Aetna says it was required to review his medical record. Which when it saw his last bloodstream work had been done three years previously for Kaiser.
Despite being told by his own physician’s office that he needed to come in for brand spanking new blood work, Washington failed to achieve this for several months until he obtained so sick he ended up within the hospital with a collapsed lung.
Once his bloodstream was tested, Aetna resumed addressing his infusions and pre-certified your pet for a year. Despite that, according to Aetna, Washington continued to miss infusions.
Washington’s match counters that Aetna ignored their treating physician, who appealed in the behalf months before his hospitalization that the treatment was medically required “to prevent acute and extensive problems. ”
“Aetna is blaming me with regard to what happened, ” Washington told CNN. “I’ll just be honest, it’s shocking to me. I want Aetna to be designed to change. ”
During his videotaped deposition within October 2016, Iinuma — who else signed the pre-authorization denial — said he never read Washington’s medical records and knew alongside nothing about his disorder.
Questioned about Washington’s condition, Iinuma said he was not sure what the drug of choice will be for people who suffer from his condition.
Iinuma further states he’s not sure what the symptoms are usually for the disorder or what may happen if treatment is instantly stopped for a patient.
“Do I know what happens? inch the doctor said. “Again, I’m unsure…. I don’t treat it. ”
Iinuma said this individual never looked at a patient’s healthcare records while at Aetna. He says which was Aetna protocol and that he centered his decision off “pertinent information” provided to him by a health professional.
“Did a person ever look at medical records? inch Scott Glovsky, Washington’s attorney, requested Iinuma in the deposition.
“No, I did not, inch the doctor says, shaking his mind.
“So in your custom and practice in making choices, you would rely on what the nurse experienced prepared for you? ” Glovsky requests.
Iinuma stated nearly all of his work had been conducted online. Once in a while, he mentioned, he might place a phone call to the doctor for more details.
How many times might he contact a nurse over the course of a month?
“Zero to one, inch he said.
Glovsky told CNN he had “never heard such explosive testimony within two decades of deposing insurance company evaluation doctors. ”
Aetna defended Iinuma, who is no longer with the company, stating in its legal brief that he counted on his “years of experience” like a trained physician in making his choice about Washington’s treatment and that this individual was following Aetna’s Clinical Plan Bulletin appropriately.
“Dr. Iinuma’s decision was right, ” Aetna said in courtroom papers. “Plaintiff has asserted all through this litigation that Dr . Iinuma had no medical basis to get his decision that 2011 medical tests were outdated and that Dr . Iinuma’s decision was incorrect. Plaintiff is definitely wrong on both counts. ”
In its demo brief, Aetna said: “Given that will Aetna does not directly provide health care to its members, Aetna has to obtain medical records from associates and their doctors to evaluate regardless of whether services are ‘medically necessary. ‘ Aetna employs nurses to gather the particular medical records and coordinate with all the offices of treating physicians, plus Aetna employs doctors to make the real coverage-related determinations.
“In addition to applying their scientific judgment, the Aetna doctors plus nurses use Aetna’s Clinical Plan Bulletins (‘CPBs’) to determine what healthcare records to request, and whether or not those records satisfy medical requirement criteria to support coverage. These CPBs reflect the current standard of treatment in the medical community. They are regularly updated, and are publicly available for any kind of treating physician to review. ”
Jones, the Ca insurance commissioner, said he could not comment specifically on Washington’s situation, but what drew his attention was the medical director’s admission associated with not looking at patients’ medical information.
“What I am just responding to is the portion of his depositing transcript in which he said because the medical director, he wasn’t really reviewing medical records, ” Jones told CNN.
He said his investigation can review every individual denial associated with coverage or pre-authorization during the healthcare director’s tenure to determine “whether it had been appropriate or not for that decision to become made by someone other than a physician. inch