Health Insurer Under Fire

Aetna’s former medical director admits “he never looked at patients’ records when deciding whether to approve or deny care.” That stunning admission came under oath from Dr. Jay Ken Iinuma, who was the health insurance giant’s medical director for Southern California from 2012 to 2015.

From CNN.com:

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
According to Forbes.com, “This admission was made during a deposition in a lawsuit brought against Aetna by Gillen Washington, a 23 year old with common variable immune deficiency (CVID) who was denied coverage for an infusion of intravenous immunoglobulin (IVIG) four years ago.”
Iinuma said he never looked at a patient’s medical records when employed by Aetna, instead basing his coverage decisions on information provided to him by nurses, per CNN. He also said that was protocol at the company and that most of his decisions were conducted online, with a rare call to a nurse to ask for more details.
Becker’s Hospital Review added, “Aetna defended its practices and the coverage decision in Mr. Washington’s case.”

“Medical directors — and all of our clinicians — take their duties and responsibilities as medical professionals incredibly seriously,” Aetna said in a statement to CNN. “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.”

MedCityNews.com quoted Dr. Pedram Hendizadeh, a podiatrist and the founder and CEO of UMA Health, as saying, “It’s obviously infuriating to have a doctor in that position who’s not really looking at medical records. 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.”

Check out some of the links above and let us know what you think about this startling revelation involving the nation’s third largest health insurance provider. Are you surprised? Concerned? And what do you believe the next steps should be? Generating meaningful conversations around the health stories making headlines is another way we are working toward our long-term goal of one day making Arizona the Healthiest State in the Nation!

 

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