California and Colorado are looking closely at the health insurance company Aetna’s pre-authorization and appeals processes. The investigations follow the admission of Jay Iinuma, MD, a former Aetna medical director, that he never reviewed patient medical records when deciding whether to authorize treatment.
Dr. Iinuma revealed this in an October 2016 deposition for a lawsuit concerning the insurance company’s denial of coverage for treatment of a patient with an autoimmune disorder. He stated that he acted in accordance with Aetna’s pre-authorization process by relying on Aetna-employed nurses to provide him necessary information about patient history.
State insurance departments stress that Aetna’s pre-authorization and appeals procedures could harm patients. “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,” California Insurance Commissioner Dave Jones, JD, said in a statement.
The controversy is occurring amid Aetna’s proposed $69 billion merger with CVS Health, which is currently under review by the U.S. Department of Justice. Federal antitrust reviews are generally concerned with whether a merger hurts competition, but state regulators’ antitrust investigations are usually more extensive and also can consider how a merger affects public interest. The results of these prior-authorization findings could affect the details of the merger.
Source: Modern Healthcare, February 13, 2018.