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Aetna is now facing another set of claims calling into question its determination and payment methodology for out-of-network reimbursement. On September 4, 2015, six surgical centers in Texas (Allied Center for Special Surgery) filed suit in Harris County District Court against Aetna Health Inc. and Aetna Life Insurance Company (Aetna), claiming that Aetna underpaid or denied payment of more than 900 claims for treatment dating back to 2006. The lawsuit claims that Allied was underpaid nearly $34 million for the services provided. This case is one in a growing trend brought by providers seeking redress for how insurers are determining and paying <a href="http://www.healthlawupdate.com/2015/08/texas-hospital-strikes-back-at-aetna/">out-of-network claims</a>, including insurers’ alleged decisions to deliberately or creatively underpay or deny claims.

Allied contends it was providing “medically necessary care and treatment” to Aetna’s members on an out-of-network basis, according to the complaint. As a provider without a managed care agreement with Aetna, Allied’s reimbursement was determined solely by “Aetna’s own methodology.” Despite being an out-of-network provider, Allied contends that it contacted Aetna “on or before the date of services being rendered” and “obtained verification of insurance and received preauthorization for all treatment to be provided to the Aetna members at issue …” Allied went on to perform the services and later submitted claims to Aetna for payment based on Allied’s usual and customary charges. Allied complains that, after the claims were submitted, Aetna improperly paid the claims based upon “its ‘allowed’ amount which was not disclosed at the time of verification.” The “allowed” amount, Allied contends, was around 30 percent of Allied’s billed charges.

Allied brought claims for negligence; negligent misrepresentation; statutory violations of the Texas Insurance, Administrative, and Business and Commerce Codes; promissory estoppel; and ERISA violations. The lawsuit seeks actual damages of “at least $33,995,920.71,” as well as treble and punitive damages and attorneys’ fees.

The case is Allied Center for Special Surgery, Austin LLC, et al., v. Aetna Health Inc., in the 151st Judicial District of Harris County, Texas; Cause No. 2015-52344.

Texas Surgical Centers: Aetna Improperly Denies or Underpays Out-of-Network Claim