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.