Pediatric group claims Aetna doesn't review medical charts in lawsuit alleging insurer values profits over care

Aetna's new headquarters
A lawsuit from Pediatrix Medical Group claims Aetna's sole motivation is to increase profits. (Aetna)

A national physician group is suing Aetna for “improperly interfering with medical care,” alleging the insurer tried to claw back payments for necessary patient care, furthering accusations that the company fails to review patient charts.

Pediatrix Medical Group of Florida, the nation’s leading provider of specialty pediatric physician services, and its parent company, Mednax, claim Aetna has tried to reduce claims payments using a flawed analysis and strong-armed providers with a scheme the companies say is “motivated by a desire for ever-increasing profits.”

The physician group, with employs 1,750 specialists across 35 states, also raised concerns that the insurer does not review medical charts when evaluating claims payments, referencing a CNN report in February that highlighted a deposition from Aetna’s former medical director Jay Ken Iinuma, M.D., who said he never looked at patient records when making coverage decisions.

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That sparked condemnation from many in the healthcare industry and prompted an investigation by several states including California. Aetna has said Iinuma’s deposition was “taken out of context to create media and courtroom leverage,” adding that it is a “gross misrepresentation” of its review process.

RELATED: Aetna slams 'gross misrepresentation' of clinical review process

But according to the complaint (PDF) filed by Pediatrix and Mednax with the U.S. District Court in the Southern District of Florida, Aetna uses its “sheer size and enormous market power” to “threaten providers with frivolous lawsuits based on flawed statistical analyses of the providers’ claims for payment.” Pediatrix claims Aetna retains a lawyer that uses “back-door means” to deny claims by conducting an investigation outside of the civil discovery process and hiring private investigators to question former employees.

“These legal actions were filed to protect physicians who are employed by Mednax’s affiliated medical practices and the critically ill and/or premature newborns that they care for each and every day in order to ensure that physicians, not insurance companies, retain the right to make medical decisions for their patients,” Luke Nikas, an attorney with Quinn Emanuel Urquhart & Sullivan, LLP who represents Pediatrix and Mednax, said in a statement to FierceHealthcare.

“MEDNAX firmly believes that a physician’s professional judgment is of paramount importance,” he added. “We have full confidence in the appropriateness of our practices and wish to resolve this matter expeditiously.”

RELATED: Aetna whistleblower accuses CVS of false claims, unsealed lawsuit reveals

A spokesperson for Aetna said the company does not comment on pending litigation but referenced a previous statement it issued refuting the CNN report. Iinuma also issued a sworn statement (PDF) clarifying his previous deposition, adding that he "generally would have reviewed a portion of the patients' medical record that was provided to Aetna."

Pediatrix, however, claims the insurer—which is in the midst of finalizing a $69 billion deal with CVS—prioritizes profits over necessary medical care.

“Defendants do not care what the medical charts reflect,” the complaint states. “Defendants do not concern themselves with the actual care being delivered. Their sole motivation is to recover from or deny monies to the healthcare providers to reduce the costs of care that they must pay for—even justified and life-saving care— and increase their profit margins.”

Update: According to Law360, Aetna sued Mednax and Pediatrix claiming providers exaggerated the conditions of newborns to order additional unnecessary tests, resulting in $50 million in overbilling. The suit was filed in the Pennsylvania Court of Common pleas this week. 

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