CVS's Acquisition of Aetna, Takes a Turn, CA Investigating Aetna

Iinuma worked with the insurance company from March 2012 to February 2015. He now owns his own family practice physician in Arcadia

Iinuma worked with the insurance company from March 2012 to February 2015. He now owns his own family practice physician in Arcadia

In a deposition for a suit filed by a college student, the former medical director for Aetna revealed that he never looked at a patient's medical records before deciding whether to approve care.

Iinuma, who served as medical director for Aetna for Southern California from March 2012 to February 2015, said he was following Aetna's training, in which nurses reviewed records and made recommendations to him.

California's Insurance Commissioner Dave Jones has launched an investigation into the insurer after CNN showed him a transcript of Dr. Jay Ken Iinuma's testimony.

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"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.

"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".

Even more, the former Aetna's medical director's testimonies came up during the lawsuit opened against Aetna by a former client, Gillen Washington.

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Dave Jones the Insurance Commissioner of California said his office was looking at how common a practice of defaulting to recommendations and reviews from nurses was in Aetna, which is the third largest US insurance supplier. Washington says that he was denied insurance coverage for a procedure he said would help the rare immune disorder he has. Aetna denies that charge, saying Washington did not comply with its request for new blood work before it approved the treatment. During his videotaped deposition in October 2016, he said he never read Washington's medical records and had little idea on how to treat it.

Jones told CNN he expected that doctors would review requests for care.

On Sunday night, through a prepared statement, Aetna said the state commissioner had not yet contacted them but looked forward to giving its explanation of the process of clinical reviews.

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The statement added that medical directors at Aetna are trained to complete a review of all medical information available, which included medical records, to make a decision that is well informed. 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.

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