Investigation Follows Stunning Admission by Aetna

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#1 Investigation Follows Stunning Admission by Aetna

Postby thaiworthy » Thu Feb 15, 2018 11:54 am

Last year, Aetna acquired BUPA. In December, CVS acquired Aetna. This week California launches an investigation following a stunning admission by Aetna's past medical director. I have a policy for my boyfriend and been having customer service problems with BUPA. Not big problems, but they have been developing symptoms of bad customer service according to some of my Thai friends. This story is the icing on the cake.

I am dumping BUPA post haste.


(CNN) California's insurance commissioner has launched an investigation into Aetna after learning a former medical director for the insurer admitted under oath he never looked at patients' records when deciding whether to approve or deny care.

California Insurance Commissioner Dave Jones expressed outrage after CNN showed him a transcript of the testimony and said his office is looking into how widespread the practice is within Aetna.

"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.

Aetna, the nation's third-largest insurance provider with 23.1 million customers, told CNN it looked forward to "explaining our clinical review process" to the commissioner.

California insurance commissioner Dave Jones launched the investigation after being contacted by CNN.

The California probe centers on a deposition by Dr. Jay Ken Iinuma, who served as medical director for Aetna for Southern California from March 2012 to February 2015, according to the insurer.

During the deposition, the doctor said he was following Aetna's training, in which nurses reviewed records and made recommendations to him.
Jones said his expectation would be "that physicians would be reviewing treatment authorization requests," and that it's troubling that "during the entire course of time he was employed at Aetna, he never once looked at patients' medical records himself."

"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," Jones told CNN.

"That's why we've contacted Aetna and asked that they provide us information about how they are making these claims decisions and why we've opened this investigation."

The insurance commissioner said Californians who believe they may have been adversely affected by Aetna's decisions should contact his office.
Members of the medical community expressed similar shock, saying Iinuma's deposition leads to questions about Aetna's practices across the country.

"Oh my God. Are you serious? That is incredible," said Dr. Anne-Marie Irani when told of the medical director's testimony. Irani is a professor of pediatrics and internal medicine at the Children's Hospital of Richmond at VCU and a former member of the American Board of Allergy and Immunology's board of directors.

"This is potentially a huge, huge story and quite frankly may reshape how insurance functions," said Dr. Andrew Murphy, who, like Irani, is a renowned fellow of the American Academy of Allergy, Asthma and Immunology. He recently served on the academy's board of directors.


This story was published Dec. 3, last year, the $69 billion deal promises to reshape the health industry:

CVS Health said on Sunday that it had agreed to buy Aetna for about $69 billion in a deal that would combine the drugstore giant with one of the biggest health insurers in the United States and has the potential to reshape the nation’s health care industry.

The transaction, one of the largest of the year, reflects the increasingly blurred lines between the traditionally separate spheres of a rapidly changing industry. It represents an effort to make both companies more appealing to consumers as health care that was once delivered in a doctor’s office more often reaches consumers over the phone, at a retail clinic or via an app.

The merger comes at a time of turbulent transformation in health care. Insurers, hospitals and pharmacy companies are bracing for a possible disruption in government programs like Medicare as a result of the Republicans’ plan to cut taxes. Congress remains at an impasse over the future of the Affordable Care Act, while employers and consumers are struggling under the weight of rising medical costs, including the soaring price of prescription drugs. And rapid changes in technology have raised the specter of new competitors — most notably Amazon.

A combined CVS-Aetna could position itself as a formidable figure in this changing landscape. Together, the companies touch most of the basic health services that people regularly use, providing an opportunity to benefit consumers. CVS operates a chain of pharmacies and retail clinics that could be used by Aetna to provide care directly to patients, while the merged company could be better able to offer employers one-stop shopping for health insurance for their workers.

But critics worry that customers could also find their choices sharply limited. The deal risks leaving patients with less choice of where to get care or fill a prescription if those with Aetna insurance are forced to go to CVS for much of their care.
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