Health care insurer Aetna is on the legal and PR defensive following a report that some called “shocking.”
California’s insurance commissioner, Dave Jones, launched an investigation into Aetna’s practices and protocols after its former medical director admitted under oath that he didn’t view patient files when approving or denying claims.
CNN first broke the story, reporting the following exchange from the deposition of Dr. Jay Ken Iinuma, Aetna’s medical director for Southern California from March 2012 to February 2015:
Iinuma said he never looked at a patient’s medical records while at Aetna. He says that was Aetna protocol and that he based his decision off “pertinent information” provided to him by a nurse.
“Did you ever look at medical records?” Scott Glovsky, Washington’s attorney, asked Iinuma in the deposition.
“No, I did not,” the doctor says, shaking his head.
“So as part of your custom and practice in making decisions, you would rely on what the nurse had prepared for you?” Glovsky asks.
Iinuma said nearly all of his work was conducted online. Once in a while, he said, he might place a phone call to the nurse for more details.
How many times might he call a nurse over the course of a month?
“Zero to one,” he said.
The deposition is part of a lawsuit that college student Gillen Washington filed against Aetna, alleging breach of contract after he was denied coverage for an intravenous immunoglobulin infusion—a necessary treatment for Washington’s common variable immunodeficiency.
In this particular case, Iinuma admitted that he had minimal if any knowledge of the medical condition, common variable immune deficiency (CVID), that Washington suffered from. He was also not clear about what the most effective drug would be to treat the patients’s condition, the symptoms of CVID, or even the consequences of the abrupt discontinuation of therapy for the condition.
“Do I know what happens?” Iinuma said. “Again, I’m not sure…I don’t treat it,” according to the deposition, as reported by CNN.
Aetna gave CNN the following written statement:
“We have yet to hear from Commissioner Jones but look forward to explaining our clinical review process.
“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.”
The company also provided the following statement on its website—which it embedded under a large purple banner on the top of its newsroom titled, “Aetna responds to CNN report”:
Aetna medical directors review all necessary available medical information for cases that they are asked to evaluate. That is how they are trained, as physicians and as Aetna employees. In fact, adherence to those guidelines, which are based on health outcomes and not financial considerations, is an integral part of their yearly review process.
While we can’t comment on the alleged actions of a former employee due to ongoing litigation, we want to be clear that our policies always have our members’ best interests in mind.
The health care insurer has remained silent on social media, however—where it has been slammed with criticism and outrage.
Communicators who work in the health care space should be on the alert for potential negative ramifications stemming from CNN’s report.
Dr. Mohamed Zuhdi Jasser, who specializes in internal medicine and nuclear cardiology in Phoenix, tweeted:
This case should make every patient doubt veracity of insurance company denials. We PCPs spend hundreds of unfunded hours fighting denials to now hear doctors pushing denials aren’t even reviewing the patient’s charts but only rubber stamping RN reviews!? https://t.co/Ig9GgVVh9k
— M. Zuhdi Jasser (@DrZuhdiJasser) February 11, 2018
Besides causing a reputational crisis for Aetna, Iinuma’s admission could also affect other organizations in the health care space. At the very least, it can lead consumers to question organizations’ transparency and decrease trust in them.
How would you advise Aetna to handle this report, Ragan/PR Daily readers?