More on Compliance & Legal

California Department of Insurance is investigating Aetna's claims and request for prior authorization policies

A deposition reveals former medical director never looked at patient medical records, but Aetna says correct guidelines were followed.

Susan Morse, Senior Editor

The California Department of Insurance has opened an investigation against Aetna over allegations that the insurer's former medical director in the state denied claims and requests for prior authorization without reviewing patient medical records.

 "I have directed the California Department of Insurance to open an investigation of allegations regarding Aetna's practices in denying claims and requests for prior authorization for care," California Insurance Commissioner Dave Jones confirmed online. "The department is also investigating Aetna's utilization review process. If a health insurer is making decisions to deny coverage without a physician ever reviewing medical records that is a significant concern and could be a violation of the law."

[Also: DOJ wants more information on $69 billion CVS Health and Aetna merger]

The California department is seeking more information from Aetna about their claims denial process, Jones said.

The Department of Managed Health Care in California is also investigating Aetna.

[Also: Blame game rages between Aetna, claims administrator over envelope privacy breach]

The investigation is based on an October 2016 deposition given by Jay Ken Iinuma, MD, Aetna's former medical director in California, who denied coverage for treatment of an autoimmune disease in 2014. The patient sued Aetna over the denial.

During the deposition, Iinuma said he never personally read the medical records of patients, but based his decisions whether to approve or deny based on information given to him by nurses employed by Aetna who did review the records.

"Because the first part of this question was I'd have to review medical records, and that's not true because the nurse preparing the case would look through the medical director -- medical records and provide me with the information required, such as lab values," the deposition said.

Iinuma said in answer to a question that he did not know the  standard treatment for patients that had common variable immunodeficiency, but imagined it would be the drug of choice.

The patient has sued Aetna over the decision.

Aetna has paid for each and every treatment the individual suing Aetna has received since he first submitted a claim under his health plan in 2014, the insurer said by statement.

"He remains an Aetna member today, and we continue to pay for his treatments," Aetna said. "The only interruption in his treatment was the result of the individual defying his doctor's orders and refusing to provide necessary bloodwork."

Each infusion can cost up to $20,000, according to a CNN story, that was cited by Aetna in its statement. 

Aetna confirmed that despite being told by his doctor's office that he needed to come in for new blood work, the patient failed to do so for several months until he got so sick he ended up in the hospital with a collapsed lung.

Aetna said the story was pushed by the patient's attorneys days before the trial was scheduled to begin.  

"We want to be 100 percent clear with our members, customers, partners and the public: Dr. Iinuma's deposition was taken out of context to create media and courtroom leverage, and is a gross misrepresentation of how the process actually works," Aetna said.  "Medical records were in fact an integral part of the clinical review process during Dr. Iinuma's tenure at Aetna, consistent with his training."

Iinuma made this clear in a sworn statement, Aetna said.

"In addition to reviewing the relevant portions of submitted medical records, it was also generally my practice to review Aetna nurses' summaries, notes, and the applicable Aetna Clinical Policy Bulletins.  After reviewing the relevant, submitted portions of the medical record, the nurse's notes, and the Clinical Policy Bulletin(s), I would apply my medical training, experience, and judgment to reach an appropriate coverage determination," Iinuma said in the sworn statement.

Iinuma adhered to guidelines that are based on health outcomes and not financial considerations, Aetna said.

Twitter: @SusanJMorse
Email the writer:

Show All Comments