Health

Aetna sues over its ‘mysterious revaluation program’

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The orthopedic surgery practice sued Aetna on Wednesday, arguing that the failure of the Hartford, Connecticut insurer to disclose its “covert reassessment program” of supplier requirements violated state and federal laws.

The lawsuit, filed in the US District Court for the Middles of Florida, arose because Aetna Life changed the cost of spine surgery and implantation procedures performed by the Surgery Center of Viera, an outpatient surgical center that specializes in laser welding and reconstructions. …

A Melbourne, Florida-based medical professional saw a patient identified as CS who suffered from a number of spinal conditions that caused him severe pain, according to the lawsuit. This person was insured under a corporate plan administered by Aetna under the Employee Retirement Benefits Act. Viera Surgical Center considered the operation “medically necessary” for the patient and provided Aetna with prior authorization for the procedure, which the insurer approved, the complaint said.

In July 2018, the provider used CS and then billed Aetna $ 223,988 for the procedure, noting that Viera Surgical Center expected Aetna to change the claim price. Viera Surgical Center expected Aetna to either negotiate the invoice directly with the supplier, offer a refund based on a “reasonable and usual estimate” of the average amount paid in the market from an unbiased pricing source, or change the claim price in accordance with the guidelines. established by MultiPlan, with which Aetna had a contract, and the rates to which the provider agreed, the lawsuit says. New York-based MultiPlan is a cost management company that helps payers and service providers agree on disputed bills.

But instead, Aetna relied on a “secret” revaluation strategy to pay Viera Surgical Center approximately $ 33,380, stating that the CS plan allowed the insurer to reduce the amount paid to a “recognized or reasonable fee,” i.e. the suit said.

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Viera Surgical Center contacted Aetna to find out how the reimbursement rate is calculated. The supplier also hired a lawyer who approached the insurer twice about the bill. Aena did not respond to any of the requests.

By ignoring the requests of Viera Surgical Center for information, Aetna violated the laws under which the provider is entitled to reasonable compensation for their services. The lawsuit says the insurer also violated its contract with the supplier by not reimbursing surgeons for a reasonable service fee.

According to ERISA, insurers must disclose their administrative details to suppliers and face fines of up to $ 110 a day for withholding this information, the lawsuit says. Viera Surgical Center is seeking to force Aetna to disclose a strategy for re-evaluating its administrative records, as well as refunding more than $ 89,000 for ignoring its requests under federal law.

Aetna did not respond to an interview request.


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