New Jersey hospital sues Aetna over $30M in unpaid claims
The case turns on when the plan has to begin paying for inpatient care.
RWJ Barnabas Health and affiliated acute care hospitals have sued Aetna Health and Aetna U.S. Healthcare, two arms of CVS Health, over what it says are about $30 million in unpaid Medicare Advantage plan claims.
RWJ has accused the Aetna Medicare plans of misinterpreting Centers for Medicare and Medicaid Services rules governing when the Aetna plans must pay for inpatient care.
Aetna makes the denials “based on the false contention that the services were not medically necessary as inpatient services,” RWJ assets in a complaint filed Monday in a state court in Monmouth County, New Jersey.
RWJ Barnabas runs a nonprofit academic health system that includes 14 hospitals and has about 9,000 affiliated physicians.
Representatives for Aetna could not immediately be reached for comment.
RWJ Barnabas says it has filed the suit as a result of a protracted, unresolved financial dispute.
“We continue to provide to all patients, regardless of this reimbursement dispute, including individuals covered by Aetna health plans,” a representative for RWJ Barnabas said.
The suit could have a direct effect on employers that use Aetna plans to provide retiree health benefits in New Jersey.
The suit could also be a sign of hospital-payer turmoil that could lead to health systems hungrier than ever to do business with employer-sponsored health plans but also hungrier than ever to increase revenue from commercial plan patients.