A newly unsealed whistleblower lawsuit claims that Aetna misrepresented its provider network to secure lucrative Medicaid contracts in Pennsylvania.
The suit was originally filed in 2017 and saw an amended complaint in January, which was unsealed earlier this month. In the suit, former care management nurse Carol Wessner said she reported multiple times to superiors at Aetna Better Health of Pennsylvania that patients were being assigned to primary care doctors who were falsely represented as in-network.
Aetna Better Health of Pennsylvania CEO Jason Rottman and Alice Rottman, director of its quality management division, told Wessner to "refrain from recording her findings in writing and, ultimately, to stop reporting her findings altogether," according to the lawsuit.
Wessner also says she was fired in retaliation for repeatedly attempting to report her findings.
Aetna, which is now a subsidiary of CVS Health, said in a statement to Fierce Healthcare that it intends to "vigorously defend itself" if the case moves forward.
"Aetna is pleased that after reviewing all of the evidence, the government chose not to participate in the lawsuit. Aetna denies the allegations in the complaint, and intends to vigorously defend itself should the relator choose to move forward with her non-intervened complaint," the insurer said. "Aetna places the highest priority on the health and wellbeing of its members, and we provide access to quality care through a comprehensive provider network, including in Pennsylvania."
"Plaintiff’s allegation that Aetna has network adequacy deficiencies across the country is irresponsible and unrelated to the DOJ’s investigation," Aetna said.
Medicaid managed care organizations are contractually held to network adequacy standards. In Pennsylvania, MCOs are paid in a capitated per member, per month model, with the insurer covering their medical costs.
As such, if a member is seeing a PCP that is unavailable, they're less likely to seek out care, reducing what the MCO is paying out without cutting their intake from the state's Medicaid program. This was the financial incentive behind the scheme, according to the lawsuit.
The false networks were crucial to Pennsylvania's decision to award contracts to Aetna in 2010 and 2014, according to the lawsuit.
"ABHP is aware that its provider network does not meet its contractual adequacy standards," the lawsuit says. "However, in both the contract procurement and in periodic reporting, ABHP represented to the government that ABHP's network did meet its contractual adequacy standards."