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California Launches Investigation into Aetna Patient Records Review

Posted  February 12, 2018

By the C|C Whistleblower Lawyer Team

On Sunday CNN reported on a new investigation of Aetna, the country’s third largest insurance provider, by California Insurance Commissioner Dave Jones after a former medical director admitted in a deposition that he never looked at patients’ medical records before approving or denying care. The admission came in a deposition for a lawsuit filed by Gillen Washington in California alleging that Aetna denied coverage for intravenous immunoglobulin infusions to treat his common variable immunodeficiency that nearly led to his death.

Dr. Jay Ken Iinuma, a former medical director for Aetna for Southern California from March 2012 to February 2015, stated that he did not review patient medical records and instead relied on recommendations provided by nurses. The exchange went as follows: “Did you ever look at medical records?” Scott Glovsky, Washington’s attorney, asked Iinuma in the deposition. “No, I did not,” Dr. Iinuma responded. “So as part of your custom and practice in making decisions, you would rely on what the nurse had prepared for you?” Glovsky asks. “Correct.” Iinuma responded.

For its part Aetna defended Dr. Iinuma by saying he relied on his years of experience to make decisions and that his decision in the Gillen Washington case was correct. California Insurance Commissioner Jones said “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 revelation has caused some medical ethics experts to call for a more transparency and accountability from private insurers in how coverage decisions are made. If the Insurance Commission’s probe determines a violation has occurred, there are monetary penalties for each individual violation. Given the possibility that this admission could taint thousands of coverage decisions the penalties could be severe.