The states’ inquiries and the medical director’s admission, which drew scorn from the medical neighborhood, are a public relations nightmare for Hartford, Conn.-based Aetna, and places a microscope on the insurance coverage business’s pre-authorization and appeals processes. It may additionally hamper the nationwide insurer’s capacity to merge with pharmacy large CVS Health.
California Insurance Commissioner Dave Jones on Monday confirmed he’s launching an investigation into Aetna’s processes in denying claims and requests for prior authorization for care, in addition to its utilization evaluate course of. Later that day, Colorado’s insurance coverage division mentioned it will be asking questions on Aetna’s compliance with state legislation relating to customers’ rights to enchantment a protection choice.
The two insurance coverage departments had been reacting to an October 2016 deposition of Dr. Jay Iinuma, who labored as Aetna’s medical director for Southern California from 2012 to 2015, in a lawsuit regarding Aetna’s denial of protection for therapy of a affected person’s autoimmune illness in 2014.
In the deposition, Iinuma mentioned that though he was answerable for overseeing the preauthorization of care, he by no means checked out sufferers’ medical data throughout his tenure. Instead, he relied on nurses employed by Aetna to evaluate the medical data and feed him pertinent data, equivalent to lab values.
The deposition was first reported by Kaiser Health News in June 2017, however spurred an investigation after CNN confirmed the deposition to Jones.
“I wouldn’t look at the medical records. I’d look at what the nurse provided, the information that the nurse provided,” Iinuma mentioned in his deposition. He additionally mentioned Aetna educated him to make pre-authorization selections this manner.
In a press release, Aetna mentioned its medical administrators “review all necessary available medical information for cases that they are asked to evaluate. That is how they are trained, as physicians and as Aetna employees. In fact, adherence to those guidelines, which are based on health outcomes and not financial considerations, is an integral part of their yearly review process.”
But state insurance coverage departments fear that Aetna’s pre-authorization and appeals processes may hurt sufferers.
“If a health insurer is making decisions to deny coverage without a physician ever reviewing medical records that is a significant concern and could be a violation of the law,” Jones mentioned in a press release.
Iinuma’s deposition drew scorn from the medical neighborhood, and the states’ investigations into Aetna’s inside processes are dangerous optics for a corporation hoping to merge with CVS Health. The U.S. Justice Department is now reviewing the proposed $69 billion merger.
Federal antitrust critiques are involved solely with whether or not a merger harms competitors, however state regulators’ antitrust investigations are normally broader in scope and also can think about whether or not a merger serves the general public curiosity, defined Tim Greaney, an antitrust skilled with the University of California Hastings College of the Law.
So whereas Aetna’s pre-authorization processes do not relate to the basics of the merger, it may nonetheless have an effect on the best way state regulators see the tie-up.
And if CVS, which has tried to undertaking itself as an organization dedicated to enhancing affected person’s well being, is in search of a purpose to get out of the merger, this might be a superb one, mentioned Mark Pauly, professor of healthcare administration on the University of Pennsylvania’s Wharton School.
Pauly additionally identified that the previous medical director’s admission will not be as dangerous because it sounds. Aetna serves greater than 22 million members. It’s exhausting to see how the medical director may view every affected person medical report for the hundreds of requests for protection Aetna possible receives.