CLINICAL REVIEW? A former Aetna medical director says nurses decided whether to deny coverage after they, and not him, reviewed patients' records.
A former medical director for Aetna says he never reviewed patients' medical records before approving or denying coverage, a shocking admission that has sparked an investigation into the insurance giant's clinical review process.
Rather than review the records himself, nurses reviewed the records and made recommendations to him, per company policy, says Jay Ken Iinuma, MD, a medical director for Aetna from 2012 to 2015.
A CNN investigation uncovered the practice.
The California's insurance commissioner will examine how frequently Aetna's medical directors examine patient records before making a decision on care.
Dr. Iinuma's admission came out in a deposition, during which the doctor said the practice was merely part of Aetna's training, in which he got medical record information secondhand from nurses.
"Claims and preauthorization requests are held hostage while payers make repeated requests for hundreds and hundreds of pages of records," says Tammy Tipton, president of Appeal Solutions. "What is the effect? A demoralized healthcare team, which can’t deliver timely care because it is buried in paperwork."
