Skip to main content
Sister Publication Links
  • ESG: THE IMPLEMENTATION IMPERATIVE
Subscribe
  • Sign Up Free
  • Login
  • Subscribe
  • News
    • Current News
    • Providers
    • Insurance
    • Digital Health
    • Government
    • Finance
    • Technology
    • Safety & Quality
    • Transformation
    • People
    • Regional News
    • Digital Edition (Web Version)
    • Patients
    • Operations
    • Care Delivery
    • Payment
    • Midwest
    • Northeast
    • South
    • West
  • Unwell in America
  • Opinion
    • Bold Moves
    • Breaking Bias
    • Commentaries
    • Letters
    • Vital Signs Blog
    • From the Editor
  • Events & Awards
    • Awards
    • Conferences
    • Galas
    • Virtual Briefings
    • Webinars
    • 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
    • Digital Health Transformation Summit
    • ESG: The Implementation Imperative Summit
    • Leadership Symposium
    • Social Determinants of Health Symposium
    • Women Leaders in Healthcare Conference
    • Best Places to Work Awards Gala
    • Health Care Hall of Fame Gala
    • Top 25 Diversity Leaders Gala
    • Top 25 Women Leaders Gala
    • - Hospital of the Future
    • - Value Based Care
    • - Hospital at Home
    • - Workplace of the Future
    • - Digital Health
    • - Future of Staffing
    • - Hospital of the Future (Fall)
  • Multimedia
    • Podcast - Beyond the Byline
    • Sponsored Podcast - Healthcare Insider
    • Video Series - The Check Up
    • Sponsored Video Series - One on One
  • Data Center
    • Data Center Home
    • Hospital Financials
    • Staffing & Compensation
    • Quality & Safety
    • Mergers & Acquisitions
    • Data Archive
    • Resource Guide: By the Numbers
    • Surveys
    • Data Points
  • MORE+
    • Contact Us
    • Advertise
    • Media Kit
    • Newsletters
    • Jobs
    • People on the Move
    • Reprints & Licensing
MENU
Breadcrumb
  1. Home
  2. Legal
September 14, 2021 05:32 PM

Aetna lied about provider network to win Medicaid contracts, suit alleges

Nona Tepper
  • Tweet
  • Share
  • Share
  • Email
  • More
    Reprints Print
    Aetna

    Aetna illegally secured contracts with Pennsylvania's Medicaid program by misrepresenting the number of pediatric providers in its network, according to a federal whistleblower lawsuit unsealed Tuesday.

    The insurer benefited from this alleged fraud because the lack of providers limited access to care, saving Aetna money. Aetna Better Health of Pennsylvania CEO Jason Rottman and Alice Jefferson, director of the company's quality management division, are named as defendants along with the company in the lawsuit, which was filed in the Western District of Pennsylvania.

    Aetna, a CVS Health subsidiary, violated the federal False Claims Act by operating a shadow network of primary care providers for children enrolled in HealthChoices, the state's Medicaid managed care program, the lawsuit alleges. The plaintiff also says Aetna has similar problems with provider networks in all 13 states where it has Medicaid contracts.

    Because Aetna was paid on a per-member per-month basis to manage enrollees' care, the company was able to keep a larger portion of the cash paid through the federally funded program because children were unable to find providers in their network, the suit alleges.

    The Pennsylvania Human Services Department would not have inked five-year contracts with Aetna in 2010 or 2014 if regulators had accurate provider directories, the federal government says.

    Aetna denies the allegations and will vigorously defend itself in the case, the spokesperson wrote, a spokesperson wrote in an email Friday. The whistleblower's allegation that the company has network deficiencies nationwide irresponsible and unrelated to the Justice Department investigation, the spokesperson wrote.

    Whistleblowers file qui tam lawsuits on behalf of the government, which can intervene, allow the whistleblower to pursue the claims and oversee the proceedings, or move to dismiss. The government intervenes in fewer than 25% of whistleblower cases and typically only gets involved when there is a high likelihood of success and a potentially large settlement, legal experts said.

    Aetna is currently engaged in a separate lawsuit over why it was not chosen during Pennsylvania's most recent round of Medicaid managed care bids.

    Former Aetna quality management nurse consultant Carol Wessner is the whistleblower who initiated the lawsuit in January.

    When Wessner started working at Aetna in 2013, the insurer's early and periodic screening, diagnostic and treatment testing rates were far lower than the state average, which the company blamed on parental negligence, according to the suit. Aetna also claimed that pediatric providers were discriminating against Medicaid beneficiaries by refusing them service.

    The federal government requires that Medicaid beneficiaries under age 21 have access to annual screenings. But after investigating the cause of the low screening rate, Wessner discovered that many of the primary care providers assigned to the company's nearly 100,000 child beneficiaries were either not contracted with Aetna, dead, operating out of state or did not treat children at all, the complaint says.

    In February 2015, for example, Aetna assigned nearly 500 children to receive annual screenings at the Philadelphia Health Department's eight federally qualified health centers, even though the insurer terminated its contracts with them the previous year, the complaint says.

    In 2016, almost half of the primary care providers Aetna assigned to perform periodic health screenings had no experience doing those test during the prior year, according to the lawsuit. Only 21% of primary care providers had seen at least half of their assigned patients during that year, the lawsuit says.

    After bringing these concerns to her managers, including Rottman, Wessner was transferred from her role "in retaliation," according to the complaint. Jefferson, her direct manager, told her to stop reporting the issues in writing and only discuss them verbally. Wessner alleges Jefferson also forbade her from speaking to coworkers or provider relations staff. Eventually, the company fired her after an "organizational review," the lawsuit says. Aetna made no effort to update its provider networks after being alerted about the inaccuracies of its listings, according to the complaint.

    The government is seeking to be compensated for at least twice as much as it incurred in damages related to false billing, the maximum civil penalty allowable under the False Claims Act, reimbursement for court costs, attorneys fees, and any other awards the court deems equitable and just for Wessner.

    The amended complaint was submitted Jan. 11 and unsealed on Tuesday.

    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
    PBM3_i.png
    Ohio files price-fixing lawsuit against Express Scripts, Humana, Prime
    outcome-main_1.jpg
    Google investor describes troubling rumors heard before Outcome Health fell
    Most Popular
    1
    More healthcare organizations at risk of credit default, Moody's says
    2
    Centene fills out senior executive team with new president, COO
    3
    SCAN, CareOregon plan to merge into the HealthRight Group
    4
    Blue Cross Blue Shield of Michigan unveils big push that lets physicians take on risk, reap rewards
    5
    Bright Health weighs reverse stock split as delisting looms
    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 © 1996-2023. Crain Communications, Inc. All Rights Reserved.
    • News
      • Current News
      • Providers
      • Insurance
      • Digital Health
      • Government
      • Finance
      • Technology
      • Safety & Quality
      • Transformation
        • Patients
        • Operations
        • Care Delivery
        • Payment
      • People
      • Regional News
        • Midwest
        • Northeast
        • South
        • West
      • Digital Edition (Web Version)
    • Unwell in America
    • Opinion
      • Bold Moves
      • Breaking Bias
      • Commentaries
      • Letters
      • Vital Signs Blog
      • From the Editor
    • Events & Awards
      • 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
      • Conferences
        • Digital Health Transformation Summit
        • ESG: The Implementation Imperative Summit
        • Leadership Symposium
        • Social Determinants of Health Symposium
        • Women Leaders in Healthcare Conference
      • Galas
        • Best Places to Work Awards Gala
        • Health Care Hall of Fame Gala
        • Top 25 Diversity Leaders Gala
        • Top 25 Women Leaders Gala
      • Virtual Briefings
        • - Hospital of the Future
        • - Value Based Care
        • - Hospital at Home
        • - Workplace of the Future
        • - Digital Health
        • - Future of Staffing
        • - Hospital of the Future (Fall)
      • Webinars
    • Multimedia
      • Podcast - Beyond the Byline
      • Sponsored Podcast - Healthcare Insider
      • Video Series - The Check Up
      • Sponsored Video Series - One on One
    • Data Center
      • Data Center Home
      • Hospital Financials
      • Staffing & Compensation
      • Quality & Safety
      • Mergers & Acquisitions
      • Data Archive
      • Resource Guide: By the Numbers
      • Surveys
      • Data Points
    • MORE+
      • Contact Us
      • Advertise
      • Media Kit
      • Newsletters
      • Jobs
      • People on the Move
      • Reprints & Licensing