Skip to main content
Sister Publication Links
  • ESG: THE NEW IMPERATIVE
Subscribe
  • My Account
  • Login
  • Subscribe
  • News
    • Current News
    • COVID-19
    • Providers
    • Insurance
    • Government
    • Finance
    • Technology
    • Safety & Quality
    • Transformation
    • People
    • Regional News
    • Digital Edition (Web Version)
    • Patients
    • Operations
    • Care Delivery
    • Payment
    • Midwest
    • Northeast
    • South
    • West
  • Digital Health
  • Insights
    • ACA 10 Years After
    • Best Practices
    • Special Reports
    • Innovations
  • Data/Lists
    • Rankings/Lists
    • Interactive Databases
    • Data Points
  • Op-Ed
    • Bold Moves
    • Breaking Bias
    • Commentaries
    • Letters
    • Vital Signs Blog
    • From the Editor
  • Awards
    • Nominate/Eligibility
    • 100 Most Influential People
    • 50 Most Influential Clinical Executives
    • Best Places to Work in Healthcare
    • Excellence in Governance
    • Health Care Hall of Fame
    • Healthcare Marketing Impact Awards
    • Top 25 Emerging Leaders
    • Top 25 Innovators
    • Diversity in Healthcare
    • Women in Healthcare
    • - Luminaries
    • - Top 25 Diversity Leaders
    • - Leaders to Watch
    • - Luminaries
    • - Top 25 Women Leaders
    • - Women to Watch
  • Events
    • Conferences
    • Galas
    • Virtual Briefings
    • Webinars
    • Custom Media Event: ESG Summit
    • Transformation Summit
    • Women Leaders in Healthcare Conference
    • Social Determinants of Health Symposium
    • Leadership Symposium
    • Health Care Hall of Fame Gala
    • Top 25 Women Leaders Gala
    • Best Places to Work Awards Gala
    • Top 25 Diversity Leaders Gala
    • - Hospital of the Future
    • - Value Based Care
    • - Supply Chain Revenue Cycle
    • - Hospital at Home
    • - Workplace of the Future
    • - Strategic Marketing
    • - Virtual Health
  • Listen
    • Podcast - Next Up
    • Podcast - Beyond the Byline
    • Sponsored Podcast - Healthcare Insider
    • Video Series - The Check Up
    • Sponsored Video Series - One on One
  • MORE +
    • Advertise
    • Media Kit
    • Newsletters
    • Jobs
    • People on the Move
    • Reprints & Licensing
MENU
Breadcrumb
  1. Home
  2. Legal
October 13, 2021 04:52 PM

Aetna hit with a provider suit over its 'mystery re-pricing program'

Nona Tepper
  • Tweet
  • Share
  • Share
  • Email
  • More
    Reprints Print
    aetna_i.jpg

    An orthopedic surgical practice sued Aetna on Wednesday, alleging the Hartford, Connecticut-based insurer's failure to reveal its "mystery re-pricing program" of provider claims violates state and federal laws.

    The lawsuit, filed in the U.S. District Court for the Middle District of Florida, arises from Aetna Life Insurance Company re-pricing a spinal surgery and implant procedure conducted by Surgery Center of Viera, an ambulatory surgical center that specializes in laser fusion and repair operations.

    The Melbourne, Florida-based provider had seen a patient, identified as C.S., who suffered from a number of spinal conditions that left them in severe pain, according to the suit. The individual was covered under a company plan administered by Aetna through the Employee Retirement Income Security Act. Surgery Center of Viera deemed surgery as "medically necessary" for the patient and submitted a prior-authorization for the procedure to Aetna, which the insurer approved, the complaint said.

    In July 2018, the provider operated on C.S. and later billed Aetna $223,988 for the procedure, mentioning that Surgical Center of Viera expected Aetna to re-price the claim. Surgical Center of Viera expected Aetna to either directly negotiate the bill with the provider, offer reimbursement based on a "reasonable and customary assessment" of the average amount paid in the market from an unbiased pricing source, or re-price the claim according to guidelines set by MultiPlan, which Aetna had a contract with and the rates the provider had agreed to, the suit said. New York-based MultiPlan is a cost-management company that helps payers and providers come to agreement over contentious bills.

    But instead, Aetna relied on a "secret" re-pricing strategy to pay Surgery Center of Viera approximately $33,380, saying that under C.S.' plan, the insurer had a right to reduce the amount paid to a "recognized or reasonable charge," the suit said.

    Surgery Center of Viera reached out to Aetna to ask how it calculated the reimbursement rate. The provider also hired an attorney, who reached out to the insurer twice about the bill. Aetna did not respond to either request.

    By ignoring Surgery Center of Viera's requests for information, Aetna violated laws that say the provider is entitled to reasonable compensation for its services. The insurer also breached its contract with the provider, by failing to reimburse surgeons at a reasonable rate for the service, the lawsuit said.

    Under ERISA, insurers must reveal to providers their administrative record and face a fine of up to $110 per day that they withhold this information, the suit says. Surgery Center of Viera aims to force Aetna to reveal its administrative record's re-pricing strategy, as well as recoup more than $89,000 for ignoring its requests under federal law.

    Aetna did not respond to an interview request.

    Letter
    to the
    Editor

    Send us a letter

    Have an opinion about this story? Click here to submit a Letter to the Editor, and we may publish it in print.

    Recommended for You
    supreme-court-healthcare-ok_WEB_i.jpg
    Healthcare groups react to Supreme Court abortion ruling
    blue-gavel-with-money2_i.png
    Supreme Court sides with HHS, not hospitals, in DSH payment case
    Sponsored Content
    Daily Dose Newsletter: Sign up to receive a late afternoon weekday roundup of that day’s breaking news and developments in healthcare.
    Get Newsletters

    Sign up for enewsletters and alerts to receive breaking news and in-depth coverage of healthcare events and trends, as they happen, right to your inbox.

    Subscribe Today
    MH Magazine Cover

    MH magazine offers content that sheds light on healthcare leaders’ complex choices and touch points—from strategy, governance, leadership development and finance to operations, clinical care, and marketing.

    Subscribe
    Connect with Us
    • LinkedIn
    • Twitter
    • Facebook
    • RSS

    Our Mission

    Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data.

    Contact Us

    (877) 812-1581

    Email us

     

    Resources
    • Contact Us
    • Advertise with Us
    • Ad Choices Ad Choices
    • Sitemap
    Editorial Dept
    • Submission Guidelines
    • Code of Ethics
    • Awards
    • About Us
    Legal
    • Terms and Conditions
    • Privacy Policy
    • Privacy Request
    Modern Healthcare
    Copyright © 1996-2022. Crain Communications, Inc. All Rights Reserved.
    • News
      • Current News
      • COVID-19
      • Providers
      • Insurance
      • Government
      • Finance
      • Technology
      • Safety & Quality
      • Transformation
        • Patients
        • Operations
        • Care Delivery
        • Payment
      • People
      • Regional News
        • Midwest
        • Northeast
        • South
        • West
      • Digital Edition (Web Version)
    • Digital Health
    • Insights
      • ACA 10 Years After
      • Best Practices
      • Special Reports
      • Innovations
    • Data/Lists
      • Rankings/Lists
      • Interactive Databases
      • Data Points
    • Op-Ed
      • Bold Moves
      • Breaking Bias
      • Commentaries
      • Letters
      • Vital Signs Blog
      • From the Editor
    • Awards
      • Nominate/Eligibility
      • 100 Most Influential People
      • 50 Most Influential Clinical Executives
      • Best Places to Work in Healthcare
      • Excellence in Governance
      • Health Care Hall of Fame
      • Healthcare Marketing Impact Awards
      • Top 25 Emerging Leaders
      • Top 25 Innovators
      • Diversity in Healthcare
        • - Luminaries
        • - Top 25 Diversity Leaders
        • - Leaders to Watch
      • Women in Healthcare
        • - Luminaries
        • - Top 25 Women Leaders
        • - Women to Watch
    • Events
      • Conferences
        • Transformation Summit
        • Women Leaders in Healthcare Conference
        • Social Determinants of Health Symposium
        • Leadership Symposium
      • Galas
        • Health Care Hall of Fame Gala
        • Top 25 Women Leaders Gala
        • Best Places to Work Awards Gala
        • Top 25 Diversity Leaders Gala
      • Virtual Briefings
        • - Hospital of the Future
        • - Value Based Care
        • - Supply Chain Revenue Cycle
        • - Hospital at Home
        • - Workplace of the Future
        • - Strategic Marketing
        • - Virtual Health
      • Webinars
      • Custom Media Event: ESG Summit
    • Listen
      • Podcast - Next Up
      • Podcast - Beyond the Byline
      • Sponsored Podcast - Healthcare Insider
      • Video Series - The Check Up
      • Sponsored Video Series - One on One
    • MORE +
      • Advertise
      • Media Kit
      • Newsletters
      • Jobs
      • People on the Move
      • Reprints & Licensing