Aetna, CIGNA Cases Put Different Spin on Claims Fraud

Article excerpt

WASHINGTON -- Recent lawsuits against Aetna, CIGNA, and other insurers have put an entirely different spin on reimbursement issues, John Hartwig said at a forum sponsored by the American Health Lawyers Association.

Much of the federal government's work on health care fraud has centered on what the providers are doing, said Mr. Hartwig, a former deputy inspector general for investigations at the Department of Health and Human Services. "When you look at some of the issues [these suits] have raised, they're really the reverse of what the issues have been with providers for the past 25 years."

For example, one allegation in the suits has been that the insurers are routinely "downcoding" provider claims--reducing the level or intensity of the service performed to a lower level, and therefore a lower payment. "But all I heard about as a federal agent was [physician] 'upcoding'" of claims for a higher payment, said Mr. Hartwig, senior manager for dispute consulting at Deloitte & Touche, Philadelphia.

Similarly, the suits allege that the insurers routinely "bundled" unrelated services together to provide less reimbursement. "For 25 years at the federal government, we probably had an 'unbundling' project every 6 months," he said.

These cases turned health care law on its head in other ways as well, said Bruce Goldstein, a health care attorney in Berwyn, Pa. In general, provider contracts are "nightmares" to deal with, but one thing is abundantly clear: If the contract clearly states that the insurer must pay the provider for services rendered and then the insurer doesn't pay, "that's a cause of action for a breach of contract. That is what the Aetna case and the CIGNA case are all about. They're class action breach of contract suits," he said. …