Aetna got into provider’s suit for “mysterious revaluation program”

The orthopedic surgical practice sued Aetna on Wednesday, saying an insurer from Hartford, Connecticut, had not disclosed its “mysterious revaluation program” of vendor bids, violating state and federal laws.

The lawsuit, filed in the U.S. District Court for the Central District of Florida, arises because the life insurance company Aetna changed the prices for spine surgery and implantation procedure conducted by the Vieira Surgical Center, an outpatient surgical center specializing in laser melting and repair operations.

According to the lawsuit, a provider from Melbourne, Florida, saw a patient identified as CS who was suffering from a number of spinal diseases in which they were experiencing severe pain. The individual was covered by the company’s plan, which is managed by Aetna through the Employee Revenue Act. Vieri Surgical Center considered the operation “necessary from a medical point of view” of the patient and submitted to Aetna prior permission for the procedure, which the insurer approved, the complaint said.

In July 2018, the provider operated on CS and later billed Aetna $ 223,988 for the procedure, mentioning that Vieri Surgical Center expects Aetna to overestimate the claim. Vieri Surgical Center expects Aetna to either reconcile the bill with the provider, offer compensation based on a “reasonable and customary estimate” of the average amount paid in the market from an impartial price source, or re-evaluate the requirement according to the guidelines established by MultiP Aetna has a contract, and the rates agreed by the supplier are stated in the lawsuit. New York MultiPlan -is a cost management company that helps payers and providers agree on disputed accounts.

But instead, Aetna relied on a “secret” re-pricing strategy to pay Vieri Surgical Center approximately $ 33,380, stating that under the CS plan, the insurer is entitled to reduce the amount paid to a “recognized or reasonable fee”. suit said.

Vieri Surgical Center asked Etna to calculate the compensation rate. The provider also hired a lawyer who twice approached the insurer for the account. Etna did not respond to any inquiries.

Ignoring Viera Surgical Center’s requests for information, Aetna violated laws that say the provider is entitled to reasonable compensation for its services. The insurer also breached the contract with the supplier by not paying surgeons at reasonable rates for services, the lawsuit said.

Under ERISA, insurers must disclose their administrative documents to suppliers and face fines of up to $ 110 a day if they contain that information, the lawsuit said. Vieri Surgical Center aims to get Aetna to disclose the price conversion strategy in its administrative report, as well as return more than $ 89,000 for ignoring its requests under federal law.

Etna did not respond to the interview request.

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