Aetna, Optum ‘dummy code’ lawsuit resumes

Aetna and OptumHealth face another round in a legal battle with patients who allege the companies sought to charge more cost-sharing by disguising administrative fees as medical expenses.

US District Court Judge Martin Ridinger for the Western District of North Carolina on Monday certified a class-action lawsuit that involves more than 87,700 people and nearly 2,000 health plans. According to the plaintiffs, CVS Health subsidiary Aetna and UnitedHealth Group subsidiary Optum violated their fiduciary duties under the Employee Retirement Income Security Act of 1974 through deceptive billing practices, which increased costs for policyholders and plan sponsors.

The initial plaintiff, retiree Sandra Peters, sued the companies in 2015 after her out-of-pocket expenses for physical therapy doubled under her employer-sponsored Aetna plan. Optum is included in the lawsuit because it created Aetna’s provider network of physical therapists and chiropractors.

During discovery, Aetna and Optum turned over emails indicating the companies agreed to develop “dummy codes” with the intent to “bury the fees” and pass off administrative fees as medical expenses. .

Aetna and Optum did not respond to requests for interviews.

In 2019, Ridinger sided with the defendants, concluding that Peters and the employer that sponsored her plan saved money under Aetna’s policy, and therefore the insurer and Optum did not break the law. a federal appeals court reversed that decision Supreme Court in 2021 confirmed that decision And the case was sent to the district court last year.

Based on the higher courts’ reasoning, Readinger on Monday denied Optum’s motion to dismiss and certify the class. The judge also denied Peters’ request that the class receive prospective and injunctive relief while the case is pending.

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