Rx insurance denials without viewing patient records

State launches Aetna probe after stunning admission – CNN – by Wayne Drash, CNN – Feb 2018

This is no surprise to me, except that the medical director relied on nurses to collect data and make recommendations. Even that work will soon be automated to save money.

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.

“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.

The California probe centers on a deposition by Dr. Jay Ken Iinuma, who served as medical director for Aetna for Southern California from March 2012 to February 2015, according to the insurer.

During the deposition, the doctor said he was following Aetna’s training, in which nurses reviewed records and made recommendations to him.

So he’s passing the buck by saying he was “just following orders” – the same excuse used by so many of the Nazis that participated in the death camps – and that excuse still seems to be considered valid among corporate titans.

California Insurance Commissioner Dave Jones said his expectation would be “that physicians would be reviewing treatment authorization requests,” and that it’s troubling that “during the entire course of time he was employed at Aetna, he never once looked at patients’ medical records himself.”

This makes me wonder, what exactly was he being paid for?

“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,” Jones told CNN.

The insurance commissioner said Californians who believe they may have been adversely affected by Aetna’s decisions should contact his office.

Members of the medical community expressed similar shock, saying Iinuma’s deposition leads to questions about Aetna’s practices across the country.

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.

Aetna initially paid for his treatments after each infusion, which can cost up to $20,000. But when Washington’s clinic asked Aetna to pre-authorize a November 2014 infusion, Aetna says it was obligated to review his medical record. That’s when it saw his last blood work had been done three years earlier for Kaiser.

Despite being told by his own doctor’s office that he needed to come in for new blood work, Washington failed to do so for several months until he got so sick he ended up in the hospital with a collapsed lung.

Once his blood was tested, Aetna resumed covering his infusions and pre-certified him for a year. Despite that, according to Aetna, Washington continued to miss infusions.

Washington’s suit counters that Aetna ignored his treating physician, who appealed on his behalf months before his hospitalization that the treatment was medically necessary “to prevent acute and long-term problems.”

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 nurs

Iinuma said nearly all of his work was conducted online. Once in a while, he said, he might place a phone call to the nurse for more details.

Aetna’s response

Dr. Iinuma’s decision was correct,” Aetna said in court papers. “Plaintiff has asserted throughout this litigation that Dr. Iinuma had no medical basis for his decision that 2011 lab tests were outdated and that Dr. Iinuma’s decision was incorrect. Plaintiff is wrong on both counts.”

In its trial brief, Aetna said: “Given that Aetna does not directly provide medical care to its members, Aetna needs to obtain medical records from members and their doctors to evaluate whether services are ‘medically necessary.’

Aetna employs nurses to gather the medical records and coordinate with the offices of treating physicians, and Aetna employs doctors to make the actual coverage-related determinations.

“In addition to applying their clinical judgment, the Aetna doctors and nurses use Aetna’s Clinical Policy Bulletins (‘CPBs’) to determine what medical records to request, and whether those records satisfy medical necessity criteria to support coverage. These CPBs reflect the current standard of care in the medical community. They are frequently updated, and are publicly available for any treating physician to review.”

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.”

Morality has absolutely no authority in the world of corporate profits, so this is a meaningless statement.

“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.

Our health problems are merely a convenient source of corporate income.

If he has not looked at medical records or engaged the prescribing physician in a conversation — and decisions were made without that input — then yeah, you’d have to question every single case he reviewed.”

3 thoughts on “Rx insurance denials without viewing patient records

  1. GZB

    Wow indeed. The fact that this physician on Aetna’s payroll doesn’t even look at patients records is unbelievable. It really doesn’t surprise me. It does shock me how callously the “doctor “ admitted he never looked at patients records when making a decision. Lord, how many people have been denied services and have no idea that they have been had? The almighty $$.

    Liked by 1 person

    Reply
  2. Pingback: Opioid Moderation | EDS and Chronic Pain News & Info

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