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CA to Investigate Aetna after Insurance Claim Review Admission

California's Insurance Commission is investigating Aetna after a medical director failed to review patient data before denying care.

California is investigating Aetna after a medical director did not review patient data before denying care.

Source: Thinkstock

By Thomas Beaton

- The California Insurance Commission has opened an investigation into Aetna’s medical practices after a former medical director for the company testified in court that he did not review patient records before approving or denying care.

According to a report from CNN, California Insurance Commissioner David Jones opened the investigation after being alerted to testimony that Dr. Jay Ken Iinuma denied a patient’s intravenous immunoglobulin (IVIG) transfusion without knowing the patient’s medical information. Iinuma was medical director for Aetna’s Southern California division from 2012 to 2015.

Jones told CNN that "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.”

Iinuma was deposed in response to a lawsuit submitted by an Aetna member, Gillen Washington.

Washington is suing Aetna on the basis that the company denied an IVIG treatment when he was 19.  He contends that the treatment is vital for a rare immunodeficiency. The lawsuit is expected to go to trial in the state’s superior court later in the week.

Aetna responded to the lawsuit shortly after major media outlets learned of Washington’s lawsuit and Jones’ decision to investigate.

“Aetna medical directors review all necessary available medical information for cases that they are asked to evaluate,” the company said in a public statement. “That is how they are trained, as physicians and as Aetna employees. In fact, adherence to those guidelines, which are based on health outcomes and not financial considerations, is an integral part of their yearly review process.”

“While we can’t comment on the alleged actions of a former employee due to ongoing litigation, we want to be clear that our policies always have our members’ best interests in mind.”

Aetna added that they have paid for each of Washington’s IVIG treatments since 2014, when he enrolled in an Aetna health plan. The payer also mentioned that Washington is still an Aetna member.

Aetna also posted a brief explanation of how they make coverage decisions and how clinical staff define coverage options.

“Whenever we tell members that a requested treatment is not covered, they want to know – how could we deny a procedure that their doctor believes could improve their quality of life?  Our answer is based on scientific data – or lack thereof – and our responsibility to put member safety first,” Aetna said.

“It is never easy to tell an individual or family that a treatment or procedure is not approved – it’s the hardest thing we have to do. However, our guiding principles will continue to be proven effectiveness and member safety, as determined by rigorous scientific studies.”

The payer added they developed general medical policy bulletins, the major tenets for determining medical benefits, based on peer-reviewed journals and evidence-based consensus of medical professionals.

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