Self-insured employers that use Aetna's National Advantage Program may need to have lawyers check their plan summaries.
A judge at the U.S. District Court for the District of New Jersey analyzed two separate employer health plan summaries last week in a ruling on a suit filed by two plastic surgeons who are objecting to how Aetna-administered employer plans pay National Advantage Program providers.
The summaries state that, when plan participants receive care from an Aetna National Advantage Program provider, a "pre-negotiated charge will be paid" to the provider, Judge Julien Xavier Neals writes in an opinion on the case, Redstone v. Aetna.
Aetna may have another agreement that lets it use different rules for setting reimbursement rates for the surgeons who filed the suit, but, based on the language in the patients' plan summaries, "the court can infer plaintiffs have a legal entitlement to benefits," Neals writes.
Aetna created the National Advantage Program to establish negotiated rates it can use to pay out-of-network providers.
Dr. Jeremiah Redstone, a plastic surgeon, and another plastic surgeon, Dr. Wayne Lee, participate in a provider network administered by MultiPlan, which, in turn, participates in the Aetna National Advantage program. They are seeking court permission to represent a class of physicians who disagree with Aetna about how it's interpreting National Advantage Program contracts.
Neals was ruling on Aetna's motion to dismiss Redstone and Lee's suit altogether. Neals rejected Aetna's motion to dismiss the suit. The ruling means that the plaintiffs can keep moving ahead with their suit, but it does not determine the outcome of the suit.
Representatives for the providers could not immediately be reached for comment.
Aetna, which is now a subsidiary of CVS Health, expressed disappointment about the court's decision on the procedural motion.
"We look forward to raising our substantive arguments going forward," the company said.
What it means: If employers that use the Aetna National Advantage Program want to avoid the time and expense of having a provider pay suit survive a motion to dismiss, they may want to review any provisions in plan summaries that relate to how the plan will reimburse Aetna National Advantage Program providers.
The case: Both of the employer health plans involved in the Redstone case are self-insured employer plans governed by the Employee Retirement Income Security Act.
Many health care providers and plans are involved in litigation over out-of-network billing disputes being handled by a new independent dispute resolution system created by the No Surprises Act.
The Redstone case does not involve the No Surprises Act dispute resolution problems.
Instead, the case involves possible conflicts between Aetna's agreement with MultiPlan, Redstone and Lee's agreement with the Aetna National Advantage Program and the patients' plan summaries.
Redstone agreed to accept 85% of his billed charges for patients coming in through the National Advantage Plan program. He received prior authorization for breast reconstruction surgery for a patient recovering from breast cancer, billed $226,630 for the surgery and received $20,149.23.
Lee agreed to accept 75% of his billed charges for NAP patients. He billed Aetna $102,000 for breast reconstruction surgery for his patient. Aetna approved a $5,559.37 claim for payment and applied that amount to the patient's deductible. Aetna did not pay Lee anything.
Redstone and Lee argue that their reimbursement rates should be governed by the National Advantage Plan agreements.
Aetna says it has an agreement with MultiPlan that lets it exclude providers from the National Advantage Plan arrangement.
The court's reasoning: Neals writes that, at this stage, when reviewing a motion by a defendant to dismiss a case, the judge is supposed to assume that the facts that the plaintiffs present are true, construe the plaintiffs' complaint in the light most favorable to the plaintiffs, then determine whether the facts alleged in the complaint are enough to show that the plaintiffs have a plausible claim for relief.
Even if Aetna has an agreement in place that lets it pay Redstone and Lee rates different from the rates provided through the National Advantage Program, at the motion to dismiss stage, the court "'may not consider matters extraneous to the pleadings,' except for documents 'integral to or explicitly relied upon in the complaint,'" Neals writes, citing a 1997 ruling.
If, at this stage, the court considers MultiPlan agreement or another document not cited in the complaint, that would construe the plaintiffs' complaint in a light less favorable to the plaintiffs, the judge writes.
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