Former Aetna medical director confesses to not reviewing medical records while deciding about coverage - Sovereign Health Group
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Former Aetna medical director confesses to not reviewing medical records while deciding about coverage

In a shocking case of utter negligence of duty, Dr. Jay Ken Iinuma, former medical director of Aetna, America’s third-largest insurance provider, has admitted to never reviewing patient records while deciding to accept or deny care. The revelation came during a deposition in a lawsuit on grounds of “breach of contract” and “bad faith”, and was first reported by CNN. California Insurance Commissioner Dave Jones has launched an investigation into the matter.

According to Jones, a health insurance company taking the decision to deny coverage to a patient without a physician ever reviewing the person’s medical records is possibly a violation of the law. He is extremely troubled by the revelation as he expected physicians to review the patients’ requests for treatment authorization. It was “hard to imagine” for him that during Iinuma’s tenure, there were no cases wherein the coverage-related decisions should have been made by a physician, as opposed to some other licensed professional within Aetna.

The revelation has shocked the medical community and has led to questioning of the company’s practice nationwide.

Allegations and counter-allegations

Iinuma served as medical director for Aetna for Southern California from March 2012 to February 2015. After looking at the transcript of the doctor’s testimony, Jones couldn’t believe that Iinuma “never once looked at the patients’ medical records himself during the entire course of time.” According to Iinuma, during his employment, he was simply “following Aetna’s training” that required “nurses to review records and make recommendations to him.”

Iinuma’s deposition was part of a lawsuit that was filed against Aetna by 23-year-old Gillen Washington, a college student at the time, who was deprived of a coverage by Aetna for an intravenous immunoglobulin (IVIG) infusion therapy. Diagnosed with common variable immunodeficiency (CVID) in high school and after being insured by Kaiser, Washington eventually became Aetna’s patient in January 2014. While the company initially paid for his treatments after each infusion, a review of his medical record had revealed that his last blood work was done three years earlier for Kaiser. As per the company, once his blood was tested, they had resumed his infusions and even pre-certified him for infusions for a year. As per Washington, the company’s recklessness in withholding of the benefits had almost cost him his life.

On the other hand, Aetna has rejected his allegations and said that Washington had failed to comply with the request for blood work and continued missing his infusions. According to the company,  Washington’s failure to get his blood tested for several months, despite being told by his own doctor, made him so sick that he had ended up in the hospital with a collapsed lung. Still, Aetna extended the benefits.

Iinuma lacked knowledge of disease and patient history

During the deposition in October 2016, when asked about signing the pre-authorization denial form, Iinuma confessed to have never read Washington’s medical record and also agreed about not knowing anything about the disorder, its symptoms or even the consequences. Surprisingly, he wasn’t even clear about the most effective drug to treat the disorder.

Iinuma further stated that as part of the company’s protocol, he never viewed the patient’s medical records and had always based his decisions on the applicable information that was provided to him by a nurse. He admitted that “nearly all of his work was conducted online” with a once-in-a-while phone call to a nurse, if more details were required.

Aetna has defended Iinuma saying that while the doctor is no longer with the company, he had followed the company’s Clinical Policy Bulletin appropriately and relied on his “years of experience” as a trained physician while making decisions about Washington’s treatment.

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