Regulators' Inquiries Into Aetna Claims Review Practices Not Likely to Derail CVS Merger: Lawyers

Although two states recently announced that they are taking a close look at Aetna Inc.’s practices for denying claims for health care coverage, the scrutiny is unlikely to prevent the insurance giant’s proposed merger with CVS Health from going through, corporate lawyers said.

California Insurance Commissioner Dave Jones announced Monday the opening of an investigation into Aetna’s claims denial process, its requests for prior authorization for care, and its utilization review process. Later that afternoon, Colorado Interim Insurance Commissioner Michael Conway said that his office would be making inquiries about whether Aetna’s procedure for appealing the denial of coverage for a medical procedure complies with Colorado law governing the issue.

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California’s investigation, which prompted Colorado’s heightened interest in the matter, came after CNN showed Jones a transcript of a 2016 deposition of one of Aetna’s former medical directors. During that proceeding, Dr. Jay Iinuma, Aetna’s medical director for Southern California from 2012 to 2015, appeared to say that he did not review patient records when making a decision about whether to approve or deny coverage but rather relied on nurses’ information and recommendations to him, according to the report. Iinuma’s testimony was part of a lawsuit against Aetna filed by a then-19-year-old man who was denied coverage for a procedure to treat his autoimmune disease.

Jones said in statement, “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.”

But in a statement released Wednesday morning, Hartford, Connecticut-based Aetna said that medical records were, in fact, an integral part of the clinical review process during Iinuma’s tenure at the company, and that the statement used in the CNN report was taken out of context.

“Aetna medical directors review all necessary available medical information for cases that they are asked to evaluate,” according to the statement. “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. As Dr. Iinuma stated in his deposition, his evaluation ‘was to ensure care was being provided in a safe and effective manner.’”

Aetna also said the physician made a sworn statement on Feb. 13, after the story appeared that, “in addition to reviewing the relevant portions of submitted medical records, it was also generally my practice to review Aetna nurses’ summaries, notes, and the applicable Aetna clinical policy bulletins. After reviewing the relevant, submitted portions of the medical record, the nurse’s notes, and the clinical policy bulletin(s), I would apply my medical training, experience, and judgment to reach an appropriate coverage determination.” The insurer released the physician’s redacted statement along with its own.

Dave Jones (Photo: Rich Pedroncelli/AP)