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California launches investigation into misconduct by former Aetna medical director

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The insurance commissioner has launched an investigation into major health insurance provider Aetna after learning that a former medical director never reviewed medical records before denying care. Dr. Jay Ken Iinuma admitted while under oath that he never looked at patients records when deciding to approve or deny their healthcare. This admission was made known after a lawsuit was brought forth by 23-year old Gillen Washington, who was denied coverage for an infusion that was needed just over four years ago.

CNN obtained access to the full deposition, and showed a transcript of the testimony to Dave Jones, the California Insurance Commissioner. The information has since sparked outrage at the practices of Aetna, and has ignited an investigation into how deep this misconduct reaches.

Aetna has over 23.1 million customers, and is the nation’s third-largest health insurance provider. A spokesperson for CNN told them that they are looking forward to “explaining our clinical review process” to the commissioner.

Dr. Iinuma worked as the medical director for Aetna in Southern California from 2012-2015. During his time there, he states that he was following protocol by having the nurses review the records, who would then make recommendations to him.

This of course has been seen as completely outrageous by many, including commissioner Jones. He said in a statement to CNN “It’s hard to imagine that in that entire course in time, there weren’t any cases in which a decision about the denial of coverage ought to have been made by someone trained as a physician, as opposed to some other licensed professional.” As of now, the commissioner has notified the public that if you feel you may have been affected by these practices, that you should contact his office immediately.

The investigation being launched by commissioner Jones will begin with the reviewal of every individual denial by Dr. Iinuma, in order to determine “whether it was appropriate or not for that decision to be made by someone other than a physician.” If violations are found to have occurred, there will be monetary penalties for every violation.

This has been the cause for debate among physicians who see this a massive admission that could potentially change the way health care insurance works. It goes to show just how transparent these massive insurance providers really are regarding the approval process that goes on behind the scenes.

CNN asked Aetna for a comment regarding the investigation, and they released a written statement.

“Aetna medical directors are trained to review all available medical information — including medical records — to make an informed decision. As part of our review process, medical directors are provided all submitted medical records, and also receive a case synopsis and review performed by a nurse.

“Medical directors — and all of our clinicians — take their duties and responsibilities as medical professionals incredibly seriously. Similar to most other clinical environments, our medical directors work collaboratively with our nurses who are involved in these cases and factor in their input as part of the decision-making process.”

Expect the investigation to be ongoing in the coming months, as this could have extreme consequences for Aetna, as well as more insight into how the health insurance industry operates in fairness of its customers.

Avid writer and reader with a curious mind, I'm always looking to get the most out of life! Follow me on Twitter @whatsaschoon

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