A former medical director at insurance giant Aetna admitted under oath that he never reviewed patient medical records before denying coverage.
According to Fierce Healthcare:
Aetna is facing backlash—and an investigation in California—after a former medical director testified that he never looked at patients’ medical records when making coverage decisions.
Jay Ken Iinuma, M.D., made that admission during a deposition tied to a lawsuit filed against Aetna by a college student with a rare immune disorder, CNN reported. Gillen Washington accused Aetna of denying him life-saving infusions, but Aetna contended that he failed to comply with their requests for blood work and later, once his coverage was preauthorized, continued to miss infusions.
But it’s not the case itself that is stirring up the biggest controversy—it’s what Iinuma, who was Aetna’s medical director for Southern California from 2012 to 2015, said when questioned about how the insurer determines what to cover.
California Insurance Commissioner Dave Jones has launched an investigation into Aetna and its policies to determine whether the insurance giant broke state law. The case was brought by Scott Glovsky of the Law Offices of Scott Glovsky.
1. Insurance Transparency: Aetna’s admission highlights the need for transparency on insurance denials.
Health care transparency measures should require insurance companies to provide simple, clear explanations of what they’re covering.
When a treatment is denied, patients deserve to know how that decision was reached. We routinely hear stories from patients who’ve paid their insurance premiums for years, only to discover that it doesn’t cover the treatments they need, when they need them.
“Aren’t we to expect that an experienced and knowledgeable physician review a person’s medical records before approving or denying a potentially disease-modifying therapy or treatment?” asks Forbes contributor Dr. Robert Glatter. “This opens up the obvious question of just how transparent health insurers are being with the public regarding their process for approval or denial of coverage, especially for complex medical care and procedures.”
2. Health Care by Numbers: Medical algorithms & value frameworks impose new barriers to patient access to the right treatment.
Aetna’s admission shows the real and present danger that value frameworks pose to patients. Insurance companies apply these rigid, formulaic processes that determine if patients are too costly to treat and their lives too expensive to save.
Medical algorithms are a key component of the insurance medical review process with doctors deciding based on computer programs. For example, all cases with inpatient stays for pneumonia without IV fluids, get denials. An investigation into Aetna should get to the bottom of whether IVIG therapy was denied as part of an agreed upon algorithm policy.
Most health plans use medical systems, such as McKesson Corp.’s InterQual and the Milliman Care Guidelines, for evaluating treatment decisions. These systems have long been criticized for eroding “physicians’ power to make hospital admission decisions, potentially to the detriment of patients’ health and finances.”
3. Know Your Rights & Take Action: File an appeal
If your insurer denies your claim, you have the right to an internal appeal. This means you can ask your insurer to conduct a full and fair review of its decision. To appeal the denial, you should do the following:
- Submit the appeal request. You or someone in your health care provider’s office should submit the appeal forms along with the letter from your health care provider and any additional information that your insurer requested. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
- Request an expedited internal appeal, if applicable. If your case is urgent, you should contact your insurer and ask for instructions on how to apply for an expedited internal appeal. Your situation is urgent if waiting 30 days would seriously jeopardize your health, life, or ability to regain function.
- Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the appeal, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.
Remember: If you’ve been denied, retain all paperwork and go through the process they outline in the denial letter.
4. Contact Patients Rising for Help
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