Leading insurance company, Aetna has been under investigation for insurance claim reviews by former medical director for the company. Health insurance is a tough industry to navigate to ensure proper charges and reimbursement but RT Welter is ready to help! Contact us today to see how we can help your practice so you can get back to treating patients!
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.
During the deposition, the doctor said he was following Aetna’s training, in which nurses reviewed records and made recommendations to him.
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.”
“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.
“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.”
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.
“Oh my God. Are you serious? That is incredible,” said Dr. Anne-Marie Irani when told of the medical director’s testimony. Irani is a professor of pediatrics and internal medicine at the Children’s Hospital of Richmond at VCU and a former member of the American Board of Allergy and Immunology’s board of directors.
“This is potentially a huge, huge story and quite frankly may reshape how insurance functions,” said Dr. Andrew Murphy, who, like Irani, is a renowned fellow of the American Academy of Allergy, Asthma and Immunology. He recently served on the academy’s board of directors.