Who is Making the Decisions on Your Claim?

Who is Making the Decisions on Your Claim?

Aetna’s former medical director admits that healthcare claims are often reviewed by nurses, rather than by licensed physicians when determining approval or denial of insurance benefits.

Aetna Claim Procedures Under Investigation

In a recent investigation, Aetna’s former medical director Dr. Jay Ken Iinuma admitted that he never reviewed patient medical records before approving or denying healthcare claims. He stated that records were commonly reviewed by nurses who made recommendations for approval or denial of benefits. This admission was made during a deposition in a lawsuit where coverage was denied for a common immune deficiency treatment.

An investigation was launched when Aetna denied coverage for a standard infusion of intravenous immunoglobulins (IVIG) for a 23-year-old suffering from an immune deficiency illness. During court proceedings, Aetna’s former medical director stated that he had little knowledge of the young man’s medical condition and did not know the most effective way to treat it. He admitted that he was not familiar with the symptoms or consequences of the illness. Iinuma stated in his deposition that he was following standard Aetna training and protocol where nurses reviewed patient medical records and made recommendations on claim approvals or denials. When Iinuma was asked by the patient’s attorney if he generally reviewed patient medical records as part of the approval or denial process, he said he did not.

Dr. Iinuma served as Aetna’s medical director in Southern California between 2012 and 2015. Aetna’s actions prompted California’s insurance commissioner to investigate Aetna’s relevant protocols as a potential violation of the law. He stated that licensed physicians, not nurses or other healthcare workers, are supposed to review a patient’s medical records when determining claim benefits. Since Aetna is the third-largest health insurance provider in the country, the recent investigation raises many concerns about other patients who were denied benefits for medical procedures and treatments.

Insurance companies commonly deny healthcare claims based on a number of factors, including acting in bad faith. Patients who are denied coverage for necessary medical treatments suffer the consequences of an insurer’s decision, so claim approvals and denials must be carefully reviewed by licensed physicians who have professional knowledge of health conditions.