Medicare Approval Ethics Questioned in Aetna Director’s Decisions

medical approval

Lack of compassion and understanding. This is one of the worst responses you can get from family or friends when you are sick or injured. Compassion and understanding – and Medicare approval – are what you want and expect when you go to your provider for treatment.

One of the medical directors at Aetna in Southern California has just been uncovered as every Medicare patient’s worst nightmare. Dr. Jay Ken linuma, who was director from March 2012 to February 2015, has admitted under oath that he made decisions about coverage without ever reading patients’ records.

This came to light when Aetna was sued by a 23-year-old college student with a rare immune disease. According to an article in Forbes, Gillen Washington claimed he was denied coverage for intravenous immunoglobulin (IVIG) four years before. He charged “breach of contract and bad faith,” a charge that Aetna denied, saying Washington did not “comply with their request for blood infusion.”

Iinuma had signed the denial and, in his testimony, admitted he had not only not read Washington’s records, he also had no idea how to treat the rare disease. linuma’s defense was that his Medicare approval decisions were based on information provided by nurses. He claimed that was an Aetna protocol.

The travesty was discovered by Dave Jones, the Insurance Commissioner for California, when he was shown a transcript of linuma’s testimony by CNN. Jones has asked Aetna for a description of the insurer’s procedures surrounding decisions about Medicare coverage.

Dr. Arthur Caplan, who is the founding director of the division of medical ethics at NYU Langone Medical Center, called linuma’s treatment of his client’s case an example of “fundamental immorality.” He called for more transparency – and accountability – in the approval process by private, for-profit insurers.

Aetna has claimed, counter to linuma’s testimony, its medical directors are trained to review all medical information, including records, prior to making approval decisions. They also receive a review and synopsis of the cases from nurses. Aetna says all of it medical professionals take their responsibilities seriously and decisions are made as a result of nurses and medical directors working together as part of the process.

We suggest Medicare beneficiaries familiarize themselves with the treatment approval process administered by their insurer. The more the process becomes a topic of discussion, the more insurers will be sure that Medicare approval decisions are based on careful and ethical methods. As Dr. Caplan says, we need transparency and accountability.

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