CNN reports that "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".
CNN, citing a transcript from the case, quotes Dr. Jay Ken Iinuma, who served as Aetna's medical director for Southern California, as saying he always followed Aetna's training in these matters, which he said called for nurses to review the records and make recommendations to him.
A California lawsuit has produced testimony that seems to confirm what many health insurance policyholders have long suspected.
"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 told CNN. He said it was troubling the Iinuma never looked at patients' medical records himself during the entire time he was employed at Aetna.
"It's hard to imagine that in that entire course in time, there weren't any cases in which a decision about the denial of coverage ought to have been made by someone trained as a physician, as opposed to some other licensed professional".
Dave Jones the Insurance Commissioner of California said his office was looking at how common a practice of defaulting to recommendations and reviews from nurses was in Aetna, which is the third largest US insurance supplier. The student, Gillen Washington, was denied coverage for an infusion of intravenous immunoglobulin, a treatment for an immune disorder from which he suffers. However, when the clinic where Washington went asked the insurer for pre-authorization for an infusion in November of 2014 Aetna requested a review of Washington's medical record and saw that the most recent blood work was three years prior for Kaiser.
Jones told CNN he expected that doctors would review requests for care. He was not alone in his shock. with Dr. Arthur Caplan, founding director of the division of medical ethics at New York University Langone Medical Center, describing Iinuma's testimony as "a huge admission of fundamental immorality".
On Sunday night, through a prepared statement, Aetna said the state commissioner had not yet contacted them but looked forward to giving its explanation of the process of clinical reviews. Aetna medical directors are trained to review all available medical information - including medical records - to make an informed decision.
"Medical directors - and all of our clinicians - take their duties and responsibilities as medical professionals incredibly seriously".