We had our first blockbuster health care scandal in some time over the weekend, when CNN reported that California officials were investigating Aetna after the company’s medical director said that he had never personally reviewed a patient’s medical records when making decisions about what health care the health insurer would cover.
The scandal stems from a lawsuit filed by an Aetna patient, Gillen Washington, who says the company failed to cover treatments for his rare immune disorder. From 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 his videotaped deposition in October 2016, Iinuma — who signed the pre-authorization denial — said he never read Washington’s medical records and knew next to nothing about his disorder.
Two state agencies have announced investigations into Aetna to determine whether any state laws were breached.
I don’t know about you, but my initial reaction to this story was: Okay, this sounds bad, but how bad is it really? What can we really learn from this?
So I asked around. To be honest with you, I think the broader health policy community is a little confounded about What This Means. But I picked up on two threads that are worth considering and that might help you wrap your head around this issue, which is probably going to stay in the news for a little while.
1) The immediate question: Did Aetna break any laws?
First and foremost, there is the matter of California state law. The state sets certain rules for the role of an insurance plan’s medical director in reviewing insurance claims.
Shana Alex Charles, a professor who studies insurance at California State University Fullerton, flagged one particular relevant section to me: “If the medical …read more
Source:: Vox – All