Several states are investigating Aetna, the nation’s third largest health insurance company, for denying care without appropriate review of medical records. CNN reports that a former Aetna medical director testified under oath that he never looked at patients’ medical records when determining whether to approve or deny a claim. The former medical director’s testimony speaks volumes about the failings of our commercial health insurance system.
In the case of a California patient needing treatment for a rare immune disorder, Aetna’s former medical director testified in a deposition that he relied exclusively on nurses’ notes to decide not to approve medical care. The patient is suing Aetna for breach of contract and bad faith.
Aetna has pushed back, claiming that its former medical director did review parts of the patient’s medical records and that his testimony was taken out of context. But, the former medical director failed to even acknowledge the value of having a medical doctor review medical records before deciding whether to deny what could be a life-saving treatment. Moreover, what is perhaps most troubling in this case, is that Aetna’s protocols appear not to require its medical director to have training on a particular condition or to speak to a specialist with training on that condition before deciding whether to deny coverage.
The former medical director testified that he knew almost nothing about the patient’s condition and how he might be affected if he were denied coverage for his treatment. The former medical director was clearly not equipped to make a determination on treatment even had he reviewed the patient’s medical records.
California’s insurance commissioner, on seeing Aetna’s former medical director’s deposition testimony, said that Aetna may have violated the law. In certain instances, he said, Aetna’s medical director should be reviewing patients’ medical records, not nurses. It is not clear where the California insurance commissioner stands on the propriety of a medical director making a coverage determination about a life-saving treatment for a condition about which he knows little, without first seeking advice from a specialist with expertise on the condition.
The California Department of Insurance is investigating Aetna. Colorado, Washington and Connecticut are also investigating Aetna’s medical review practices.
Aetna has more than 23 million subscribers and is in the midst of being acquired by CVS.
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- Justice Department sues United Health Medicare Advantage for fraud
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- People with Medicare spend an average of $5,500 on health care annually