Republished with permission from ProPublica, by Patrick Rucker, The Capitol Forum, and David Armstrong and Doris Burke, ProPublica

Health insurers reject millions of claims for treatment every year in America. Corporate insiders, recordings and internal emails expose the system and its harm.

When Shawn Murphy’s wife died in 2009 after a botched gallbladder surgery, he presumed the doctor who performed the operation would be forced out of medicine for good.

Dr. Pachavit Kasemsap, a former Air Force surgeon, had cut Loretta Murphy’s aorta during that common procedure, according to a database of malpractice payments kept by Florida insurance regulators. She never left the hospital and died just shy of her 40th birthday. Shawn Murphy was left to raise their two daughters, then 13 and 17, on his own.

During the weeks that Murphy prayed for his wife to recover and the months that he fought Kasemsap in circuit court in Brevard County, Florida, he didn’t know that other families had complained that their loved ones had suffered under the same doctor’s care.

Kasemsap has settled five malpractice cases for a total of $3 million, according to the Florida malpractice payment database. That includes $1 million paid to the Murphy family. In one of the cases Kasemsap settled, a patient said the doctor negligently stapled and stitched her rectum to her vagina. Kasemsap denied doing that, and in legal filings in all five cases, the doctor denied that he was negligent.

The doctor’s LinkedIn profile says his last job as a surgeon ended in December 2012, months before he settled the last of those five cases. But there was one industry ready to welcome him regardless: health insurance.

Kasemsap got a job as an insurance company medical director, where suddenly he had the power to impact the lives of far more patients than he would ever have seen in the operating room.

For most policyholders, the inner workings of their health insurer are a black box: Requests to cover treatment or pay claims go in, and approvals or rejections are spit out.

The pivotal gatekeepers inside the box are medical directors like Kasemsap. They can, without ever seeing a patient, overrule the judgment of the doctor who did and deny payment for a recommended procedure, test or medicine.

Insurers say medical directors steer patients away from unnecessary or risky care and expensive treatments for which there are less costly, equally effective alternatives. Patients and their physicians complain that insurance company doctors routinely, and wrongly, deny payment for critical lifesaving treatments because they are expensive.

The stakes are high: A refusal to pay for treatment can drive families into bankruptcy. Some patients, facing the cost, forgo care altogether. And a single medical director can rule on 10,000 cases a year, according to court testimony in a case involving Aetna. Some Cigna doctors have ruled on more than 10,000 cases in a month without opening the patient file, as ProPublica and The Capitol Forum have reported.

Despite the key role insurers’ medical directors play in the lives of patients, their identities and backgrounds, and their qualifications for making such life-altering assessments, remain largely hidden.

Many states require medical directors to be licensed physicians, but beyond that it is generally up to insurers to determine which medical professionals are fit for the job.

Patients and the doctors who treat them don’t get to pick which medical director reviews their case. An anesthesiologist working for an insurer can overrule a patient’s oncologist. In other cases, the medical director might be a doctor like Kasemsap who has left clinical practice after multiple accusations of negligence.

As part of a yearlong series about how health plans refuse to pay for care, ProPublica and The Capitol Forum set out to examine who insurers picked for such important jobs.

Reporters could not find any comprehensive database of doctors working for insurance companies or any public listings by the insurers who employ them. Many health plans also farm out medical reviews to other companies that employ their own doctors. ProPublica and The Capitol Forum identified medical directors through regulatory filings, LinkedIn profiles, lawsuits and interviews with insurance industry insiders. Reporters then checked those names against malpractice databases, state licensing board actions and court filings in 17 states.

Among the findings: The Capitol Forum and ProPublica identified 12 insurance company doctors with either a history of multiple malpractice payments, a single payment in excess of $1 million or a disciplinary action by a state medical board.

One medical director settled malpractice cases with 11 patients, some of whom alleged he bungled their urology surgeries and left them incontinent. Another was reprimanded by a state medical board for behavior that it found to be deceptive and dishonest. A third settled a malpractice case for $1.8 million after failing to identify cancerous cells on a pathology slide, which delayed a diagnosis for a 27-year-old mother of two, who died less than a year after her cancer was finally discovered.

None of this would have been easily visible to patients seeking approvals for care or payment from insurers who relied on these medical directors.

When patients look for doctors, they can first check the physicians’ education, experience and qualifications. Most states allow consumers to see if doctors have been sanctioned by a medical board for providing substandard care, and many also provide some information about malpractice payments. But that kind of up-front scrutiny isn’t possible with medical directors because patients typically don’t learn their identity until a denial arrives.

Kasemsap’s history of malpractice payments was no secret before Cigna hired him in 2019. Two years earlier, he was the subject of a front-page story in the South Florida Sun Sentinel headlined “Dangerous Doctors.” In addition to handling appeals for the insurer, Kasemsap obtained a certification through a Cigna physician leadership program and oversees the work of 13 other medical directors there, according to his LinkedIn profile. Cigna CEO David Cordani posed with him and others in a photo at a recent company leadership event.

When told Kasemsap was working in this critical role, Murphy was shocked. “This guy should not be deciding medical questions,” he said. “I don’t care if it’s an earache.”

Kasemsap wrote in an email to ProPublica and The Capitol Forum: “Please know that I carry every patient outcome with me, and those experiences reinforced my commitment to being a compassionate, detail-oriented, dedicated colleague who puts our members at the center of everything I do.” Kasemsap said he was responding on his own behalf, not Cigna’s. He did not answer other questions about his malpractice cases or his role at the insurer.

Cigna, in a statement, said all of its medical directors are board-certified, credentialed physicians and the company holds its medical directors to the same standard as doctors who participate in its network. “We use a comprehensive suite of materials and discussions to assess how our medical directors support patients efficiently and effectively,” a company spokesperson wrote.

In another statement, the spokesperson wrote, “As I’m sure you’re aware, malpractice claims against physicians are common, particularly in high-risk specialties such as surgery, and the settlement of malpractice claims does not necessarily mean that malpractice occurred.”

Between 2005 and 2014, during the time when Kasemsap settled his malpractice cases, only 6% of doctors nationwide had any paid malpractice claims and only 1% had two or more paid claims, according to a study in the New England Journal of Medicine. A study in the same journal found that while surgeons were more likely to face a claim than physicians overall, less than 5% of general surgeons paid a malpractice claim each year between 1991 and 2005.

“I can say in my 35-plus years doing this that this is the most unskilled surgeon I have ever seen in a case,” said Mac McLeod, a malpractice attorney who represented two plaintiffs who sued Kasemsap, including the woman who said Kasemsap connected her rectum to her vagina.

When asked about McLeod’s assertion, Kasemsap wrote, “This is a mischaracterization of a highly complex medical case that occurred more than 15 years ago.” Kasemsap did not say what was mischaracterized.

A Doctor Goes Sleuthing

A few days before Christmas in 2021, Terrold Dance was loaded down with electrical tools when he slipped on some ice at a worksite and went to a Colorado hospital for help. An MRI later showed that Dance had torn his rotator cuff, the muscles and tendons that surround the shoulder joint and keep the upper arm bone in the socket.

Workers’ compensation paid for the scan and some physical therapy, but that didn’t fix the problem. By the next Christmas, Dance was still in pain and couldn’t fully raise his arm over his head. A Colorado orthopedic surgeon, Dr. Braden Jones, examined Dance and concluded that he needed surgery.

“The guy had not gotten better for a year,” Jones recalled. “It was a pretty clear-cut case for surgery.”

Pinnacol Assurance, the workers’ compensation company that handled Dance’s policy, required that the surgery be authorized in advance, and the company hired a medical reviewer named Dr. Jon Erickson to scrutinize Dance’s request and medical records. Like a medical director, a contract medical reviewer for Pinnacol evaluates whether a surgery is medically necessary. In a letter to a case manager, Erickson concluded that steroid injections and some physical therapy would likely be enough to fix Dance’s problem. Pinnacol denied the request for surgery.

“I believe the mechanism of injury is somewhat questionable,” Erickson wrote, “and we would be best served by considering a program of nonoperative care which involves injections.”

The letter baffled Jones. It downplayed Dance’s shoulder injury and brushed aside the MRI report, Jones said. Erickson didn’t cite any published research or medical society guidelines to explain why an operation was not needed. Jones said that the letter was such a break from accepted orthopedic practice that he wondered if Erickson had ever been a surgeon.

So Jones decided to check. The Colorado medical board had a copy of Erickson’s medical license and an explanation for why he hadn’t set foot in an operating room in many years.

A disciplinary report from the medical board said Erickson had performed a “substandard” hip replacement surgery in 2013 that led to irreparable harm to a patient. Erickson tried in three additional operations to fix it, the disciplinary report said, but the patient had to undergo a fifth surgery elsewhere and will always walk with a limp.

That wasn’t all. The report criticized Erickson for another faulty hip replacement six months after the first. The surgery had taken place on a Friday, and by Monday the same patient was back on the operating table with a broken hip. Erickson performed a second surgery but something was wrong. An X-ray showed the problem.

Erickson had put the hip in backwards.

In a 2017 settlement with the Colorado medical board, Erickson was allowed to keep his license as long as he never performed any kind of orthopedic surgery again. As a doctor reviewing cases for an insurer, though, Erickson has the power to decide that orthopedic operations are not medically necessary, when he himself is not allowed to perform them.

In an interview, Erickson defended his decision to deny Dance’s surgery and his work overall. “This was a relatively clear-cut case,” Erickson said. He added, “What we do at Pinnacol when we review these cases is prevent a lot of inappropriate care, and we save a lot of money for our clients.”

In a statement, Pinnacol said Erickson was contracted as an independent reviewer and that he did not work directly for Pinnacol. “He is not and has never been an employee,” a spokesperson wrote, adding that Pinnacol no longer uses Erickson to review cases. “Our mission as a not-for-profit, state-chartered carrier is to serve the workers and employers of Colorado, and we would never, nor do we support denying necessary medical care ‘to save our clients money.’”

The company said its claim denial rates are “roughly half the state average.” While Pinnacol is a nonprofit insurer, it does typically return money to its customers in the form of an annual dividend.

For Jones, the experience confirmed all of his worst suspicions about medical directors.

“If you have ever seen a Lego, you know which way the hip goes,” Jones said. “I always considered these medical directors to be sellouts, but I thought an insurance company would have more dignity than to hire someone like this.”

After Jones complained to Pinnacol about Erickson’s history and the wrongheaded nature of the denial, the insurer approved Dance’s rotator cuff surgery, which he underwent earlier this year. Dance has since regained full strength and motion.

Jones was so disturbed by what he discovered that he complained to the medical board. Chief among Jones’ beefs: If Erickson is not allowed to perform orthopedic surgery due to the board action, why is he allowed to rule on insurance cases that affect what orthopedic surgeons in good standing can do? The medical board acknowledged to Jones in a September letter that his complaint remained open but declined to comment to ProPublica and The Capitol Forum. Erickson said he thought Jones’ decision to file a complaint with the medical board “was a little bit overkill.”

Trouble With Medical Boards

Doctors turn to health insurance company work for many reasons. Some do it after burning out on clinical care or a change in circumstance, such as starting a family or retiring from a practice. Many find the work rewarding, saying they can help patients by flagging care that is unnecessary or even dangerous.

The job offers good pay with potential bonuses and a set schedule without weekend work or night shifts. The median pay for medical directors at insurers like UnitedHealthcare, Cigna and Elevance is around $300,000 a year, with the high end of the salary range over $400,000, according to the job site Glassdoor.

Despite this, ProPublica and The Capitol Forum found, insurance companies still wind up employing doctors who state medical regulators have rebuked for providing shoddy care or being dishonest.

A unit of Cigna called eviCore has employed Dr. Lorraine Driscoll as an associate medical director from 2006 through at least March 2022, according to records filed with the Maryland Insurance Administration. The New Jersey medical board in 2013 found grounds for disciplining Driscoll for “dishonesty, deception, and misrepresentation and/or … for engaging in professional misconduct.”

The board reprimanded Driscoll, an obstetrician-gynecologist, for altering patient records in ways that could help her fight a 2004 malpractice case involving a child born with Down syndrome. That case, which wound up settling for $700,000, was one of six that Driscoll settled, according to her application to be certified as a medical director by the Maryland Insurance Administration. (Maryland officials approved her application.) She did not respond to calls, emails or a letter with detailed questions sent via FedEx.

Other insurers, including Aetna and UnitedHealthcare, hire eviCore to determine whether certain treatments are medically necessary.

When asked if Driscoll still works for eviCore, a company spokesperson declined to answer. In a written statement, eviCore said its medical directors are all board-certified physicians “who are dedicated to ensuring that patients receive safe, effective care guided by the latest clinical evidence.” The company added that its doctors “are held to the same legal, licensing and education requirements that physicians treating patients are held to.”

Aetna has on its in-house team Dr. Beth Ann Binkowski, an internal medicine physician who was censured and reprimanded by the New York state medical board in 2015 for failing to appropriately prescribe medications for five patients at Syracuse University with mental health conditions. Binkowski referred a reporter to Aetna for comment. A company spokesperson said all Aetna medical directors are licensed and board certified and that the company follows accreditation requirements and state and federal regulations.

UnitedHealthcare hired Dr. Dolores Rhymer-Anderson as a medical director in 2015 despite the fact that the Georgia medical board had previously reprimanded her for care related to the delivery of a baby born with severe neurological damage in 2000. She settled a related malpractice lawsuit for $2 million. In a legal filing in that malpractice case, Rhymer-Anderson denied that she was negligent and said she exercised the appropriate degree of care and skill ordinarily employed by doctors in the same circumstance.

A peer reviewer appointed by the medical board faulted Rhymer-Anderson for failing to conform to the minimum standard of acceptable and prevailing medical practice. As part of an agreement with the board in 2006, she was required to complete 20 hours of continuing medical education and pay a fine of $1,500. The board order stated Rhymer-Anderson did not acknowledge any impropriety and agreed not to contest the allegations to avoid protracted litigation.

Rhymer-Anderson excluded obstetrics from her practice before the board order, blaming the move on her experience with the lawsuit, according to a regulatory filing. She said she hoped to avoid another legal action.

But in 2008 she was sued again and settled the case for $1 million. That lawsuit faulted her work during a diagnostic procedure to evaluate a patient’s uterus. The patient went into respiratory distress and suffered a brain injury from lack of oxygen. The patient spent a month in the hospital before being transferred to a long-term care facility. The lawsuit accused Rhymer-Anderson of incorrectly administering anesthesia, failing to properly supervise a nurse assisting and failing to secure an airway by endotracheal tube.

In her application to be certified as a medical director in Maryland, Rhymer-Anderson said she settled because the plaintiff was estimating the cost of future care at $16 million, which exceeded her malpractice insurance, and she was concerned a jury award could put her personal assets at risk. She said in the Maryland filing that three expert witnesses concluded that she met the standard of care in the case. In a court filing in that case, Rhymer-Anderson said she acted within the standard of care in treating the patient and did not commit any act of negligence that resulted in injuries. (Maryland officials approved her application.)

Settlements of $1 million or more, referred to as catastrophic claims, are rare. Only 7.6% of claims saw settlements that large in a study of malpractice cases filed nationwide from 1992 through 2014. The same study found the average malpractice payment by doctors in Rhymer-Anderson’s specialty was $432,959.

Rhymer-Anderson did not respond to phone calls, emails and a letter with detailed questions sent via FedEx.

A UnitedHealth Group spokesperson said Rhymer-Anderson left the company last year. The spokesperson also wrote, “Medical directors go through a rigorous hiring process, to ensure they are qualified for the roles for which they are being considered.” He added, “We review individual performances regularly and provide ongoing training to help them with their various responsibilities.”

“Cranking Out Denials”

When an insurer shoots down a request to pay for care, the patient’s doctor can call the insurance company’s doctor to make the case for why it should be approved. This is known as a peer-to-peer review.

But doctors often complain they’re not actually speaking with peers when they call an insurer. They get exasperated when an orthopedic surgeon weighs in on a procedure to treat an irregular heartbeat or a pediatrician questions an oncologist’s plan for an adult with lung cancer.

In a survey conducted by the American Medical Association, only 2% of the doctors who responded said that health insurance medical directors were “always” appropriately qualified to assess the requested treatment. More than a third said health plan doctors were “rarely” or “never” qualified.

When Orrana Cunningham’s doctor at the MD Anderson Cancer Center in Houston asked her insurer to approve the use of expensive proton beam therapy to attack her cancer, the decision on whether to pay for the care fell to an Aetna doctor who had not treated patients in more than 20 years, according to records from a lawsuit the Cunningham family brought against Aetna.

Dr. David Massman, a medical director at Aetna, denied coverage of the treatment, ruling that it was “experimental or investigational.”

Cunningham’s radiation oncologist, Dr. Clifton Fuller, then requested a peer-to-peer call so that he could explain why proton beam therapy was the best method for treating Cunningham’s stage IV nasopharyngeal squamous carcinoma, a rare cancer located at the base of her skull. Proton beam therapy was needed, he said, because it could precisely deliver radiation to the cancer site while avoiding devastating side effects, such as loss of sight and memory, that could occur with other radiation treatments.

It was a complex procedure. Fuller wanted someone with a background in treating cancer to be on the call. Instead, he was paired with Massman, a family medicine physician who had never worked in radiation oncology and had never seen a proton beam machine.

Massman went to work for health insurers two decades ago after his Illinois medical license was placed on a four-year probation for issues related to a drug addiction, according to state licensing records. His license is in good standing now.

In their peer-to-peer call, Fuller testified in a sworn deposition, Massman acknowledged Fuller may be right that proton beam therapy was a safe treatment for Cunningham but said he “can’t do anything about it” because the therapy did not comply with an Aetna clinical policy guideline.

Appeals of the decision failed. In all, three Aetna medical directors reviewed the treatment request and subsequent appeals. None of them were radiation oncologists.

As the appeals dragged on, Cunningham grew sicker. Out of options, her husband decided to mortgage the family home and sell other assets to pay for the $92,000 treatment.

Cunningham underwent the procedure in April 2015, four months after her doctors first asked Aetna to approve it. When she returned home in May, she started to behave strangely. She didn’t recognize her husband or son. She was diagnosed with herpetic encephalitis, a disease that her family’s attorney contended was unrelated to the cancer treatment and triggered by stress. She died later that month.

Cunningham’s husband sued Aetna in Oklahoma state court, alleging that the insurer breached its contract with his wife, acted in bad faith and inflicted emotional distress.

At the trial, Massman testified that he could not recall details of his peer-to-peer call with Cunningham’s radiation oncologist, but he said that he would never tell a treating physician that they were right about a treatment Aetna was denying.

In his closing arguments at the trial, Cunningham’s lawyer, Doug Terry, condemned Aetna’s medical directors: “These doctors were not properly qualified to know the first thing about the medical issues involved here. None of them had any experience with radiation oncology or proton therapy. They were cranking out denials as fast as they could.”

Aetna’s lawyer countered that the company was proud of the medical directors who denied Cunningham’s care for “standing up for what is right.” Massman and other Aetna medical directors involved in denying Cunningham’s care sat in the front row as the company’s lawyer made his closing argument, said Terry.

The jury in 2018 awarded Cunningham’s estate and her husband $25.6 million. After Aetna appealed the jury verdict, the parties settled the case under confidential terms in 2021.

Massman did not respond to calls, emails and a letter with detailed questions sent via FedEx.

In a statement, Aetna said its “sympathies continue to be with the Cunningham family.” It said that today any clinical reviews or peer-to-peer conversations related to proton beam therapy are conducted by board-certified radiation oncologists. The company did not answer a question about efforts more generally to match specialists to the treatment requested.

“Frequent Flyers”

A small group of doctors—about 2%, termed “frequent flyers” by one study author—are responsible for 40% of medical malpractice claims in the country.

It’s unusual for doctors to make payments in multiple malpractice cases, and that can signal that a physician is providing low-quality care. In Florida, the state health department is mandated to investigate any doctor who has had three or more claims in excess of $50,000 within a five-year period.

In 2013 Dr. John Stripling stopped working as a urologist, according to a deposition he gave in a product liability case. Around that time he faced medical malpractice lawsuits from patients in two states who alleged he botched enlarged prostate procedures.

In total, Stripling settled cases with 11 former patients between 2014 and 2017 with a combined payout of $3.6 million, according to Florida Department of Health records. After receiving “malpractice information,” the Arkansas State Medical Board told Stripling in 2015 that he would have to appear before the board if he wanted to renew his license, which was expiring. He never did.

Stripling was able to maintain his license in Florida, state records show, and he began working for health insurers in 2016, according to his LinkedIn profile. His most recent job, his profile said, was as a medical director for naviHealth, a unit of UnitedHealth Group’s Optum business, where he weighed in on placements of patients released from the hospital. A UnitedHealth Group spokesperson said Stripling left naviHealth in March.

A 2014 lawsuit filed in Arkansas state court by Larry Stanley, a patient of Stripling’s, alleges that dozens of the doctor’s patients in that state and Mississippi experienced severe and unacceptable complications when the doctor performed a procedure known as transurethral laser ablation of the prostate, or TULAP. The procedure uses a laser to treat an enlarged prostate, which can otherwise cause problems with urinating.

The lawsuit alleged that a nurse who worked with Stripling reported to another urologist that 40 of Stripling’s patients who underwent the TULAP procedure experienced “unprecedented complications.” The office manager and head nurse in Stripling’s practice were so alarmed by the high rate of complications that they went directly to the chief executive officer of the company Stripling worked for, according to Stanley’s lawsuit.

After Stanley’s TULAP procedure with Stripling in 2010, he was left incontinent, had to use catheters to drain his bladder and underwent additional surgeries, according to Stanley’s suit. In a court filing in that case, Stripling denied that he was negligent or at fault. The lawsuit was dismissed after both sides said they had resolved the matter, but the court records don’t provide any additional detail. Stanley died in 2019. His son Greg recalled his father received about $300,000 in a settlement.

A steelworker in his younger years, Larry Stanley had later owned and operated a sawmill for 40 years. Greg Stanley said his father was a changed man after the surgery. He rarely left home, worried he would have wet spots on his clothes.

“This doctor butchered him,” Greg Stanley said.

In a 2012 deposition in a malpractice case in Mississippi, Stripling said he stopped doing the laser prostate operation on Dec. 7, 2010, when he had a “coming-to-Jesus meeting” with himself and concluded “this is it.” At least eight of the settlement payments made in his malpractice cases involved incidents that occurred in 2010, according to the licensing records.

Stripling said in the deposition that too many of his patients “were doing poorly” after their operations. “There was something flawed in what was being done; and I didn’t have a clear answer, but it was time to make a decision,” he said. He testified that he went back to performing an older procedure that didn’t involve a laser.

That Mississippi case later settled for $305,000, according to Florida state medical licensing records. In a court filing, Stripling said he complied with the standard of care and was not negligent in his treatment of the patient.

Stripling did not respond to phone messages, emails and letters with detailed questions sent via FedEx. The UnitedHealth Group spokesperson reiterated that the company’s medical directors go through a rigorous hiring process, that their performance is regularly reviewed and that the company provides ongoing training.

Another “frequent flyer” was Cigna’s Kasemsap, who settled five malpractice suits after denying in court filings that he was negligent.

It was in November 2006, during a colostomy reversal surgery, that Kasemsap allegedly connected a 42-year-old woman’s vagina to her rectum, according to a malpractice complaint filed in state court in St. Augustine, Florida. The mistake caused air and feces to pass through the vagina, and the patient had to undergo three more surgeries, according to the complaint.

A month later, according to allegations in another lawsuit, Kasemsap mistakenly cut a patient’s common bile duct and an artery during a gallbladder surgery. A jury found him negligent in that case and awarded the patient $600,000. Kasemsap and the patient subsequently agreed to settle the case.

Kasemsap’s malpractice insurer made another payment to a patient who said in a lawsuit that he had suffered from a mild case of hemorrhoids that Kasemsap wrongly diagnosed as a far more serious case. The doctor then negligently performed a 2007 surgical procedure that left the patient with “constant, severe physical pain and suffering, incontinence and irritation,” the complaint said.

Kasemsap settled two more malpractice cases for incidents in 2009, including one filed by Loretta Murphy’s family after her death, court records show.

Kasemsap started working for insurers in 2013, according to his LinkedIn profile, which boasts about his contributions to companies’ financial health.

As a senior medical director at Highmark, a Blue Cross Blue Shield plan, he claimed credit for saving $3 million a year by removing high-cost specialty drugs from automatic authorization, his profile said. He also said he saved the company $15 million by initiating step therapy in the treatment of macular degeneration. Step therapy generally requires patients to try less expensive treatments before more expensive ones. (When asked about Kasemsap’s profile, a spokesperson for Highmark wrote, “We can’t speak to how Dr. Kasemsap categorizes his work. Medical directors use evidenced-based guidelines and the unique clinical picture of each member’s case to render medical necessity decisions only, which is agnostic of cost.”)

Since late 2019, Kasemsap has worked at Cigna, where he not only has reviewed treatment requests but has also managed other medical directors who handle Medicare Advantage requests for care, according to his LinkedIn profile. Kasemsap has thrived in his role at Cigna, and the company made him part of its Physician Leadership Development Program, which provides business and leadership skills.

Kasemsap’s success at Cigna came as a bitter surprise to the Murphy family.

When Loretta Murphy’s daughter Amanda Cain was young, her mother would play beauty parlor with her. Murphy would do Amanda’s hair like she learned in cosmetology school, and Amanda would paint her mother’s nails—purple with pink and white flowers.

“Her favorite flower was hibiscus, so I would always try that on the toes,” said Cain, who ended up pursuing her own career in cosmetology.

A photo in a family album shows Loretta Murphy kissing her daughter Amanda Cain when Cain was a little girl. Murphy died when Cain was 17. Credit: Greg Kahn, special to ProPublica

Cain was a junior in high school when her mother went to Kasemsap to get her gallbladder removed. The procedure was only supposed to take about an hour. When more than an hour passed, Cain started to get nervous. Her grandparents were in the waiting room and eventually took her home to look after her younger sister.

The next time Cain saw her mother, she was lying in a hospital bed with a machine helping her breathe.

Murphy died a year before Cain graduated from high school. It was just one of many life events her mother never got to witness, including the birth of Cain’s two children.

That Kasemsap has any say in the well-being and health of vulnerable people is maddening, Cain said.

“What do you say about anyone that would hire this guy knowing what they know?” she asked. “How, how would they still hire him?”