Aetna hit with legal challenges to infertility coverage, Medicaid contracts

Aetna is at the center of a couple of major legal storms brewing in Pennsylvania and New York. One involves allegations over Medicaid fraud, the other questions a policy that denied services to LGBTQ patients.

A recently unsealed federal whistleblower lawsuit alleges Aetna illegally secured contracts with Pennsylvania’s Medicaid program by misrepresenting the number of pediatric providers in its network.

The insurer benefited from this alleged fraud because the lack of providers limited access to care, saving Aetna money. Aetna Better Health of Pennsylvania CEO Jason Rottman and Alice Jefferson, director of the company’s quality management division, are named as defendants along with the company in the lawsuit, which was filed in the Western District of Pennsylvania. Prosecutors say Aetna has similar problems with provider networks in all 13 states where it has Medicaid contracts.

The Pennsylvania Human Services Department would not have inked five-year contracts with Aetna in 2010 or 2014 if regulators had accurate provider directories, the federal government says.

Aetna did not respond for comment on the litigation. The insurer is currently engaged in a separate lawsuit over why it was not chosen during Pennsylvania’s most recent round of Medicaid managed-care bids.

Seperately, Aetna said it would update coverage rules for infertility treatment just two days after a woman sued the insurer over its policy that forced LGBTQ individuals to pay tens of thousands of dollars out of pocket for procedures it offered to heterosexual people with no cost-sharing.

The insurer, which is owned by CVS Health, acknowledged it improperly denied coverage to Emma Goidel, a 31-year-old covered under an Aetna plan for Columbia University students who filed the suit. At deadline, the lawsuit was still active and the attorney representing Goidel was seeking class-action status that would include more than 150,000 students at 17 universities in New York.

“Upon further review, certain costs were improperly denied after a change in New York state coverage requirements only weeks earlier,” an Aetna spokesperson wrote in an email. “Those costs will be promptly covered, and we’ll review similar cases to ensure coverage decisions were made according to new requirements. We have a history of support for the LGBTQ community, which we’ll

 continue to build on.”