By Lise Millay Stevens
There is something rotten in Denmark. Maybe it is wafting over from the U.S. health insurance industry. CNN reports that a former Aetna medical director admitted, under oath, that he never looked at patient records prior to approving or denying care, relying instead on the recommendations from nurses at the insurance giant.
The admission from physician Dr. Jay Ken Iinuma emerged in his deposition in response to a lawsuit from patient Gillen Washington, who sued Aetna for breach of contract and bad faith after the insurer refused to pay for his expensive infusions for a rare medical condition. Mr. Washington alleges that the “reckless withholding of benefits almost killed him,” CNN reports.
The network brought the case to the attention of California Insurance Commissioner Dave Jones, who commented, “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.” The commissioner opened an investigation into Aetna’s practices after CNN brought the case to his attention.
In the same report, CNN states that Aetna defended Dr. Iinuma, 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 the doctor followed Aetna’s Clinical Policy Bulletin appropriately and that Mr. Washington had missed appointments for bloodwork related to his condition.
But that doesn’t explain why Aetna’s medical director was not reviewing patient cases before denying coverage. According to CNN, Iinuma, who signed Mr. Washington’s pre-authorization denial. said during his videotaped deposition that he never read Washington’s medical records and knew next to nothing about his disorder.
Unfortunately, refusing to pay for insured patients’ treatment is not unusual in California and elsewhere. A case is pending against Health Net (currently a subsidiary of Centene Corp.) for unlawfully refusing to pay millions of dollars in claims to treatment centers in Arizona and California, according to the website of law firm Gallagher & Kennedy.
According to the California complaint, Health Net “…began categorically denying substance abuse claims submitted by California treatment centers. The claim denials were done via form letters signed by Matthew Wong, M.D.” The complaint also asserts, “The claim denials based upon lack of medical necessity contained no distinction based upon the type of substance abuse or any other key details surrounding treatment.” And a Health Net clerk, Matthew Ciganek, was “robo-signing medical necessity denials, regardless of the underlying treatment details,” the complaint alleges.
Inadequate Health Networks
Centene/Health Net is no stranger to accusations of bilking both providers and subscribers alike. In January 2018, the company made the news when a lawsuit filed in Washington state alleged that customers in 15 states who purchased Centene insurance via the Affordable Care Act exchanges could not find in-network doctors and hospitals. According to the lawsuit, “Centene misrepresents the number, location and existence of purported providers by listing physicians, medical groups and other providers—some of whom have specifically asked to be removed—as participants in their networks and by listing nurses and other non-physicians as primary care providers.”
Former Congresswoman Donna Christensen, in a recent opinion piece in the Washington Examiner on “narrow” networks, commented that as Centene/Health Net has expanded into markets that other insurance companies have abandoned, “the company is taking advantage of vulnerable Americans, falsely touting an adequate provider network when the actual plans are so skimpy that many critics question whether they even meet minimum coverage requirements.” She added, “This practice completely violates consumers’ rights.” Ms. Christensen currently serves on the board of Consumers for Quality Care.
Death by Bureaucracy
In another California lawsuit filed against Health Net in 2017, the family of a woman who died awaiting a liver transplant alleged that she was the victim of Health Net’s disregard for her ailing health, according to a report in the Daily Breeze. When Health Net had no in-network provider qualified to perform the transplant, the insurer dithered for months, allegedly searching for an out-of-network liver transplant specialist. The woman died before she even had a transplant consultation.
According to the news report, her family’s attorney, Travis Corby commented, “No person in this country should be forced to wait months just to receive an initial consultation for life-saving treatment. [She] died without even having a chance at receiving the care she deserved.” Mr. Corby added, “HMOs like Health Net…should not be permitted to make patients wait in perilous condition while it spends months ‘negotiating’ a contract and looking to save itself money on care that should be immediately available to its insureds,” Corby added. “It is death by bureaucracy.”
The great irony is that Centene has been making billions of dollars in profits off Obamacare and other plans (the company posted a whopping $239 million profit in the third quarter of 2017 alone, up 22 percent from the same period last year). The company’s stock has been a hot commodity in recent months. Their CEO, Michael Neidorff, is the highest paid executive in the industry, raking in nearly $22 million in 2016, $411,800 of which was received as stock options and $12,829,500 as stock, according to salary.com.
The rich get richer while the insured get sicker. Is this the health care America deserves? When even having insurance means there no available network, claims are denied, procedures delayed…and patients die? It is time to hold insurers accountable. Healthy Americans are money in the bank.