Connecticut, Colorado, and Washington Join California in Aetna Probe

Colorado, Washington, and Connecticut have joined California in investigating Aetna, CNN reported Wednesday, after a former medical director for the insurer admitted in a deposition that he never looked at patients' complete medical records when deciding whether to approve or deny care.

Colorado, Washington, and Connecticut have joined California in investigating Aetna, CNN reported Wednesday, after a former medical director for the insurer admitted in a deposition that he never looked at patients' complete medical records when deciding whether to approve or deny care.

California began its investigation recently after being alerted to the statement by a CNN report.

Aetna 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, redacted statement by the former medical director, Jay Ken Iinuma, MD, in which he said he looked at relevant portions of patients' records, just not their entire records. The insurer posted a PDF of the statement, made yesterday in California, on its website. In it, the doctor claims he misunderstood the question.

CNN said it tried to get comment from the doctor for weeks before airing the story, but that he would not return calls.

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 rejected the allegations, and the suit is expected to be heard this year.

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.

At issue are Aetna's prior authorization practices. Iinuma said he relied on guidance from Aetna nurses, who prepared summaries for him based on the medical information that is available at the time of the evaluation. Prior authorizations are usually required by payers before paying for certain treatments or therapies.

Last month, a group representing healthcare providers, payers, and others released a statement calling for a streamling of the prior authorization process. The group included the American Hospital Association, America’s Health Insurance Plans, American Medical Association, American Pharmacists Association, Blue Cross Blue Shield Association, and Medical Group Management Association. The statement called for 5 ways to improve the process:

  • Use selective application of prior authorization
  • Have regular review of prior authorizaton prgram and risk adjustment
  • Have transparency and communication about prior authorization
  • Support and encourage continuity of patient care
  • Use automation to improve transparency and efficiency