Aetna's Southern California medical director testified that nurses, not doctors, decided after reviewing medical records if the insurance company would cover treatments for its insured patients, touching off an investigation by the state's insurance commissioner.
California Insurance Commissioner Dave Jones seemed stunned by the news, and a highly-placed academy physician said it could have huge impact on the relationship between insurance companies and the medical community, CNN reported.
The testimony by Dr. Jay Ken Iinuma, who served as the medical director for Aetna for Southern California from March 2012 to February 2015, was part of deposition involving a patient who is suing Aetna for breach of contract and bad faith.
Iinuma testified that the decision process was based on Aetna protocol and training.
Gillen Washington, 23, charged in his lawsuit, which could go to trial in California Superior Court this week, that Aetna recklessly withheld benefits from him after he was denied coverage for an infusion of intravenous immunoglobulin (IVIG) when he was 19, CNN said.
Intravenous immunoglobulin can cost as much as $20,000 per treatment, but it allows patients like Washington to fend off infection, CNN said.
During a videotaped deposition in October 2016, Iinuma was questioned about Washington's case and admitted that he never looked at a patient's medical records while at Aetna, per CNN. He added that it was Aetna protocol and that he based his decision off "pertinent information" provided to him by a nurse.
When asked how many times he might have called the nurse over a month to ask for more details on a case, Iinuma said in the deposition, "zero to one," per CNN.
Jones told CNN he was now launching an investigation into Aetna in light if Iinuma's deposition.
"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.
Jones told CNN that he expected doctors would be examining treatment requests and he was troubled that "during the entire course of time (Iinuma) 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. 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."
Aetna had backed up Iinuma in a legal brief, stating that his "years of experience" as a trained physician helped him make the call on Washington's case and that he followed Aetna's Clinical Policy Bulletin correctly, per CNN.
Aetna said because it does not directly provide care, it hires nurses to gather medical records and coordinate with the treating physician, while employing doctors to make actual coverage-related determinations, CNN noted.
"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," Aetna said. "These CPBs reflect the current standard of care in the medical community."
Dr. Andrew Murphy, a fellow of the American Academy of Allergy, Asthma and Immunology who serves on the academy's board of directors, told CNN that the deposition could have huge impact on the relationship between insurance companies and the medical community.
"This is potentially a huge, huge story and quite frankly may reshape how insurance functions," Murphy told CNN.
Last year, CVS Health announced that it planned to purchase Aetna for $69 billion and Larry Merlo, CVS chief executive officer, said he expected the deal to close in the second half of this year, CNBC reported.
The Justice Department requested more information last week on CVS and Aetna, the country's third-largest insurer, in light of the mega merger, CNBC said.
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