aetna

Aetna — the third-largest health insurer in the United States with over 23 million customers — is under investigation after a major scandal came to light.

California Insurance Commissioner Dave Jones says his office has opened a probe into Aetna’s business practices after a deposition by former Aetna medical director Dr. Jay Ken Iinuma was brought to his attention. In the deposition — in which the person being deposed is speaking under penalty of perjury — Dr. Iinuma said he never looked at patients’ medical records to determine whether or not their claim would be approved or denied.

“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,” Jones told CNN.

Dr. Iinuma claimed in the deposition that he was simply following his training from the health insurer, which involves nurses reviewing patients’ records and making recommendations. However, Jones countered that he found it highly problematic that Aetna’s medical director “never once looked at patients’ medical records himself.”

The revelation about Aetna’s alleged practice of denying claims without looking at medical history comes amid news that the insurance giant denied a minimally invasive form of brain surgery for a 15-year-old girl suffering from uncontrollable seizures. Aetna claimed the procedure requested — laser ablation, in which a laser burns away lesions in the brain causing seizures — was “experimental and investigational for the treatment of epilepsy because the effectiveness of this approach has not been established.”

“Clinical studies have not proven that this procedures effective for treatment of the member’s condition,” the rejection letter from Aetna read.

Mayo clinic neurosurgeon Dr. Jamie Van Gompel, who is leading a clinical trial for laser ablation, disputed Aetna’s claim that the procedure was “experimental,” telling CNN there is a wealth of data showing its effectiveness.

“It’s definitely not an experimental procedure. There’ve been thousands of patients treated with it. It’s FDA-approved,” Dr. Van Gompel said. “There’s a lot of data out there to suggest it’s effective for epilepsy.”

Bizarrely, Aetna did end up approving a far more expensive brain surgery procedure — a temporal lobectomy, which involves cutting off the top of the skull to expose the brain — even though that particular surgery was never requested by the patient’s medical team.

In 2012, the American Medical Association’s National Health Insurer Report Card found that among private health insurance companies, Aetna ranked #1 in percentage of claims denied, with a denial rate of 1.5 percent among all claims filed. United Healthcare ranked #2 with a denial rate of 1.15 percent, and Cigna came in third with a denial rate of 0.54 percent.

 

Logan Espinoza is a freelance contributor specializing in economic issues. He lives in Phoenix, Arizona with his wife and daughter. Contact him at logan DOT espinoza AT yahoo DOT com.

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