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An Aetna Medical Director Admitted He “Never Once” Reviewed Medical Records- What Now?

Emily Gillingham, Associate Attorney at Washington & West, LLC

Almost every day, one of our hospital clients refers a case to our firm that has us questioning how an insurer could have reached the decision they did.

We got a unique look into the inner workings of Aetna’s utilization management department this week with the bombshell revelation, reported by CNN, that a former Aetna Medical Director, Dr. Jay Ken Iinuma admitted in a deposition that he never looked at a patient’s medical records during his time at Aetna.

What’s worse? Dr. Iinuma further testified that this was what he was instructed to do in Aetna’s training for the position.

The State of California’s insurance commissioner has launched an investigation into the practice, and we expect other states to follow. Not only does this practice raise serious questions about the plan’s adherence to member agreements to cover medically necessary care, but it may run afoul of state regulations requiring that utilization review be performed by a qualified medical professional.

What should medical professionals do with this information? It is a good practice to have a robust denials management system in place at your practice or facility. Take advantage of peer-to-peer review rights and file appeals. Keep an eye on time frames, as a lot of contracts take away an opportunity to challenge even egregious denials after these time frames pass.

At Washington & West, some effective strategies we employ include:

As with all things, experience counts. We have a great track record of helping our hospital clients with insurance denials. If you are struggling with insurance denials, you aren’t alone! Contact us to discuss your insurance denial management.

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