Sacramento, CA - 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.
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.
The deposition came as part of a lawsuit filed against Aetna filed by Gillen Washington, a college student who suffers from a rare immune disorder. Washington was diagnosed with common variable immunodeficiency, or CVID, in high school, The case is expected to go to trial later this week in California Superior Court.
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. The doctor said he was following Aetna's training, in which nurses reviewed records and made recommendations to him.
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."
Aetna defended Iinuma, who is no longer with the company, saying in its legal brief that he relied on his "years of experience" as a trained physician in making his decision about Washington's treatment and that he was following Aetna's Clinical Policy Bulletin appropriately.
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."
"That's why we've contacted Aetna and asked that they provide us information about how they are making these claims decisions and why we've opened this investigation."
He said his investigation will review every individual denial of coverage or pre-authorization during the medical director's tenure to determine "whether it was appropriate or not for that decision to be made by someone other than a physician."
If the probe determines that violations occurred, he said, California insurance code sets monetary penalties for each individual violation. Read More...