Aetna inquiry widens over ex-medical director's comments

Three more states announced this week that they are opening investigations of Aetna after a former medical director f...

Posted: Feb 15, 2018 4:36 PM
Updated: Feb 15, 2018 4:36 PM

Three more states announced this week that they are opening investigations of Aetna after a former medical director for the insurer admitted under oath that he never looked at patients' medical records when deciding whether to approve or deny care.

Colorado, Washington and Connecticut -- where Aetna is headquartered -- have joined California in looking into the statement, which came during a sworn deposition in a lawsuit against Aetna. California began its investigation recently after being told of the statement by CNN.

Colorado, Washington and Connecticut are opening investigations

California began its investigation after an exclusive CNN report

Aetna, the United States' third-largest insurance provider with 23.1 million customers, responded Wednesday that the comments in the deposition were "taken out of context" and that "medical records were in fact an integral part of the clinical review process."

The insurer also released a sworn statement by the former medical director, Dr. Jay Ken Iinuma, in which he said he looked at relevant portions of patients' records, just not their entire records.

Iinuma served as medical director for Aetna for Southern California from March 2012 to February 2015 and, in that capacity, denied pre-authorization for a patient's treatment, asking for medical records and current bloodwork before approving it. That patient has sued Aetna for breach of contract and bad faith. Aetna has rejected the allegations, and the suit is expected to be heard soon in a California court.

On Wednesday, Connecticut became the fourth state to announce an investigation of the insurer.

"The Connecticut Insurance Department has been made aware of this serious issue, and we will be conducting a thorough investigation," Connecticut Insurance Commissioner Katharine Wade said in a statement to CNN.

During his videotaped deposition in October 2016, Iinuma acknowledged more than once that he did not look at medical records, saying he was following Aetna's training, in which nurses reviewed records and made recommendations to him. "How would you decide on your own when to actually review the medical records versus relying on what the nurse at Aetna had prepared for you?" asked Scott Glovsky, an attorney representing the patient suing Aetna.

"What percentage?" Iinuma asked.

Glovsky: "I mean, like, did you ever look at medical records or basically whenever --"

Iinuma: "No, I did not."

Glovsky: "OK. So as part of your custom and practice in making decisions, you would rely on what the nurse had prepared for you?"

Iinuma: "Correct."

Glovsky: "Instead of actually looking at yourself the medical records?"

Iinuma: "Correct."

Glovsky: "And was that throughout your -- your years at Aetna?"

Iinuma: "My tenure, yes."

Glovsky: "Was that how you were trained to do it when you joined -- first joined Aetna?"

Iinuma: "To my recollection, yes."

When Iinuma had a chance to amend comments after reviewing the deposition transcript, he signed an "errata sheet" on November 30, 2016, in which he didn't change those remarks and accepted them, under penalty of perjury, as "true and correct."

On Wednesday, as the insurer faced heavy criticism amid the growing investigations, Aetna said in a news release that in the deposition, "Iinuma appears to imply that he never relied on medical records when making coverage decisions."

"We want to be 100 percent clear with our members, customers, partners and the public," Aetna's statement says. "Dr. Iinuma's deposition was taken out of context to create media and courtroom leverage, and is a gross misrepresentation of how the process actually works. Medical records were in fact an integral part of the clinical review process during Dr. Iinuma's tenure at Aetna, consistent with his training."

The company also released a new sworn statement from Iinuma in which he appeared to indicate that he misunderstood Glovsky's questions.

"When I stated at the deposition that I never looked at a 'medical record' while at Aetna, I understood the term 'medical record' to refer to the entirety of a patient historical file containing all charts, doctors' notes, laboratory tests, and any other report generated by a treating provider for that patient," Iinuma said in the statement, which says it was signed Tuesday in Los Angeles.

"In my mind, and based on my experience, this is the definition of a patient's 'medical record' -- a record of their treatment and medical history. Not only is a patient's medical record generally a very large file or files, in my experience neither patients nor providers submit the entirety of a patient's medical record to Aetna. Patients and providers submit only portions of a patient's medical record for Aetna's review."

He went on to say that when he was being questioned by Glovsky during the deposition about reviewing medical records, "I understood him to be asking me whether I reviewed the entirety of a patient's medical record."

"In addition to reviewing the relevant portions of submitted medical records, it was also generally my practice to review Aetna nurses' summaries, notes, and the applicable Aetna Clinical Policy Bulletins," Iinuma said. "After reviewing the relevant, submitted portions of the medical record, the nurse's notes, and the Clinical Policy Bulletin(s), I would apply my medical training, experience, and judgment to reach an appropriate coverage determination."

CNN sought comment from Iinuma for weeks before the original story published. He never returned the calls. Heather Richardson, an attorney representing Aetna, also refused to answer CNN's questions.

In his deposition, Iinuma repeatedly stated that he did not look at medical records, at one point going out of his way to correct Glovsky, the patient's attorney.

Glovsky had begun to ask about the need to see medical records during a case review when Iinuma interrupted, saying, "the first part of this question was 'I'd have to review medical records' and that's not true because the nurse preparing the case would look through the medical ... records and provide me with the information required, such as lab values. So that's why I had to make a little correction there.'

Glovsky: "So you wouldn't have to look at the records yourself because the nurse had already done that for you?"

Iinuma: "Because the pertinent information was provided by the nurse."

California Insurance Commissioner Dave Jones expressed outrage after he learned from CNN about the remarks and said he was launching an investigation to get to the bottom of Aetna's denial practices.

"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," he said.

Jones said that his expectation would be "that physicians would be reviewing treatment authorization requests" and that it's troubling that "during the entire course of time he was employed at Aetna, he never once looked at patients' medical records himself."

California's Department of Managed Health Care, which also regulates insurance, also said it would look into Aetna's practices.

The medical community continued to express outrage and shock at Iinuma's deposition days after CNN's first story.

"California physicians are increasingly concerned with the growing trend of for-profit insurance companies adopting policies that restrict access to care while their profits soar," said Dr. Theodore M. Mazer, president of the California Medical Association.

"The burden of proof should rest with insurers to prove -- with an expert medical and thorough review -- why treatment should be stopped, not on treating physicians or patients."

Dr. David O. Barbe, president of the American Medical Association, said, "This is a particularly troublesome disclosure given the health insurer's ability to exert control over patients' access to vital medical care.

"To protect patients and ensure they receive the medical treatment for which they have contracted, there should be no substitute for well-informed, highly qualified clinical judgment when health insurers decide questions of medical necessity."

The deposition by Aetna's former medical director came as part of a lawsuit filed against Aetna by a college student who has a rare immune disorder.

Gillen Washington, 23, is suing Aetna for breach of contract and bad faith, saying he was denied coverage for an infusion of intravenous immunoglobulin when he was 19. His suit alleges that Aetna's "reckless withholding of benefits almost killed him."

Aetna has rejected the allegations, saying Washington failed to comply with its requests for blood work.

Washington, who was diagnosed with common variable immunodeficiency in high school, became a new Aetna patient in January 2014 after being insured by Kaiser.

Aetna initially paid for his treatments after each infusion, which can cost up to $20,000. But when Washington's clinic asked Aetna to pre-authorize a November 2014 infusion, Aetna says, it was obligated to review his medical record. That's when it saw that his last blood work had been done three years earlier for Kaiser.

In his new sworn statement, Iinuma said his decision was based on the lack of recent blood work. Without it, he said, "I could not determine that ... care was being provided in a safe and effective manner."

In his deposition, Iinuma said he wasn't sure what the drug of choice would be for people with Washington's condition, what the symptoms of the disorder are or what might happen if treatment is suddenly stopped for a patient.

Despite being told by his own doctor's office that he needed to come in for new blood work, Washington failed to do so for several months until he got so sick, he ended up in the hospital with a collapsed lung.

Once his blood was tested, Aetna resumed covering his infusions and pre-certified him for a year. Despite that, according to Aetna, Washington continued to miss infusions.

Washington's suit counters that Aetna ignored his treating physician, who appealed on his behalf months before his hospitalization that the treatment was medically necessary "to prevent acute and long-term problems."

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