Aetna Medical Director Denies Care Without Reading Submitted Medical Records

It is sort of rare to see any kind of “stunning admission” by an insurance giant. But this week’s headline about an Aetna Medical Director who made important decisions on claims without reading the medical records has been met with mounting frustration over lack of quality in payer review.

In the CNN story, Dr. Anne-Marie Irani called the admission incredible. Another physician, Dr. Andrew Murphy, states that the revelation may actually prompt changes to the system. It is important to note that both physicians who commented on the story have specialized training to treat immunology and are fellows of the American Academy of Allergy, Asthma and Immunology. Many medical billing professionals are keenly aware that an even deeper problem to the payer review process is the disregard over whether the reviewer is on a peer level with the treating physician.

“This situation is exactly why healthcare is costly and physicians are frustrated. Claims and preauthorization requests are held hostage while payers make repeated requests for hundreds and hundreds of pages of records. In the Aetna case, the hold-up was blood work requested by the Aetna medical director who has said in the deposition that he didn’t really know how to treat this disease.  So what was the blood work for? Aetna didn’t intend to look at it. They simply want to confirm its existence.  What is the effect? A demoralized healthcare team which can’t deliver timely care because it is buried in paperwork,” said Tammy Tipton, president of Appeal Solutions.

“You can appeal this type of denied care. However, physicians who participate in the appeal process are often further discouraged by the lack of quality review during appeals. It is the same problem: doctors submit hundreds of pages of records that don’t get reviewed by a peer reviewer with similar credentials as the treating provider. There are protections in place for appeals but you really have to be willing to demand a quality process with peer review and discussion of the clinical criteria. Aetna has further made this difficult by limiting physician access to higher level appeals. Last year, Aetna announced that physicians would only be allowed access to the first round of appeals. Unfortunately, many level one appeal reviews are pretty shabby and only at the level two appeal can you point out review deficiencies. This is just another example of Aetna’s lack of commitment to physician patient advocacy.”

Most of the concern over the Aetna case involved the doctor’s admission that he did not read the medical records but instead relied on a nurse reviewer’s assessment. However, the question has not been raised regarding what the Aetna medical director was looking for in that missing documentation. According to information on LinkedIn, Dr Iinuma’s specialty is family medicine, not immunology. The patient suffered common variable immunodeficiency which Dr. Iinuma was not familiar with according to this exchange from the deposition:

Questioned about Washington’s condition, Iinuma (Aetna’s Medical Director) said he wasn’t sure what the drug of choice would be for people who suffer from his (patient’s) condition. Iinuma further says he’s not sure what the symptoms are for the disorder or what might happen if treatment is suddenly stopped for a patient. “Do I know what happens?” the doctor said. “Again, I’m not sure….I don’t treat it.”

Further, not providing peer review may also be a violation of state utilization review protections which are in place to ensure that only a qualified physician would be making final treatment decisions. Aetna’s position is that there wasn’t sufficient documentation which is enough to deny without regard to other specifics. Really, though, we don’t know how relevant the missing blood work is and how its inclusion in the case file might impact treatment decisions. Another option is peer discussion where the treating physician and insurance reviewers discuss one-on-one the preauth request and relevance of any missing documentation. This does not appear to have been pursued but might have allowed the doctors to come to a workable solution other than denial of care.

Physicians often suspect that the records they submit are never looked at. However, there is one, little utilized way to make sure that records are reviewed by a peer reviewer – demand peer-to-peer discussion.

Many physicians believe peer-to-peer discussion is not widely available. However, the Affordable Care Act expanded access to the peer review process and now makes it easier to request external review of denials where peer review is the norm.

“Most practicing physicians have a very poor understanding of Insurer criteria for decision-making. They are left feeling powerless and out of their element – and therefore, disinclined to participate in peer to peer. And really, who can blame them?” states Mary Corkins, Founder of The Reimbursement Group,

Despite this increased availability subsequent to ACA protections, Corkins believes physicians are dealing with so many other legal requirements that they have not been able to concentrate much time and/or resources to conducting peer conversations. However, she says the end result of accepting the ACA regulations without fighting the denials is a lose-lose proposition.

“Of the physicians that we support, approximately 80% now participate in the peer-to-peer conversations. With educated participation in the peer-to-peer process, our approval yield is currently running at approximately 75%,” said Corkins.

Such results are impressive. Corkins says her role on these calls is to organize the clinical information so the doctor can easily reference the clinical justification for care and to assess the insurance companies compliance with the applicable peer-to-peer standards. However, she encourages healthcare organizations who are not utilizing a peer-to-peer consultant to train a staff member in the process so that this employee can serve as an internal support person for peer-to-peer conferences.

One of the most frequently cited quality issues related to peer conversation centers on the qualifications of the review peer representing the insurance carrier. The Utilization Review and Accreditation Commission (URAC) states that these reviewers must be “clinical peers” which is further described in the following terms: “Are in the same profession and in a similar specialty as typically manages the medical condition, procedure, or treatment as mutually deemed appropriate.”

Some strategies to use for ensuring a peer review are the following:

• Provide the treating physician’s background and specialty credentials. Follow this with a request for the credentials of the Payer’s clinical reviewer. Cite the URAC definition of a peer reviewer.
• Provide clinical specifics about the patient’s specific conditions/problems and how it might differ from a typical patient needing the care in question.
• Provide a detailed listing of failed conservative care treatments and medications (include dosages)
• Provide approximate number of times that the treating provider has performed the procedure/treatment in question
• Provide specifics about the treatment conversation with the patient and the patient’s response to this treatment availability.
• Provide a copy of FDA approval/clearance letter along with all available clinical guidance relating to device/procedure.