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Aetna, an Ohio Medicaid contractor, accused of denying kids care in Pennsylvania

Posted at 6:29 AM, Oct 27, 2021

The following article was originally published in the Ohio Capital Journal and published on under a content-sharing agreement.

COLUMBUS, Ohio—In a case that could have implications for Ohio, a Pennsylvania whistleblower is accusing Aetna of making it impossible for the parents of some kids on Medicaid to find doctors. The insurer then pocketed money from the state for services not rendered, the suit alleges.

Aetna denies the charges.

The case is relevant here because the Ohio Department of Medicaid in April awarded a $1 billion contract to Aetna to implement OhioRISE, an ambitious new program meant to coordinate care for 60,000 children with complex behavioral needs.

The Pennsylvania allegations, which were unsealed last month in federal court in Pittsburgh, might cast doubt on whether the company will live up to its promises in the OhioRISE program.

The allegations also add to questions of conflict and bias concerning Ohio’s procurement this year of the OhioRISE contract and six others for $22 billion worth of Medicaid managed care. Together, the contracts are meant to reshape the way the Ohio Medicaid department delivers care to 3 million people.

The Ohio Department of Medicaid was asked to comment on the Pennsylvania suit a week ago. As of Tuesday, it hadn’t responded other than to acknowledge that it had been asked for comment.

For its part, Aetna parent company CVS Health denies the accusations.

“Aetna places the highest priority on the health and wellbeing of its members, and we provide access to quality care through a comprehensive provider network, including in Pennsylvania,” spokesman Bob Joyce said in an email. “Plaintiff’s allegation that Aetna has network adequacy deficiencies across the country is irresponsible and unrelated to the (U.S. Justice Department’s) investigation.

“Aetna denies the allegations in the complaint, and intends to vigorously defend itself should (the whistleblower) choose to move forward with her non-intervened complaint. Aetna is pleased that after reviewing all of the evidence, the government chose not to participate in the lawsuit.”

The case was filed under the False Claims Act, which encourages people with knowledge of government rip-offs to blow the whistle by giving them a portion of the money recovered.

While it’s accurate that the federal government declined to intervene in the suit, the federal government is said to intervene — or take over — in only about 20% of such cases.

And in an Aug. 25 filing, the Justice Department notified the court that the federal government would continue to be listed as a plaintiff and pointed out that the case can only be dismissed if Attorney General Merrick Garland consents to it. The filing also asked U.S. Magistrate Judge Cynthia Reed Eddy to unseal the complaint, which she did the following month.

Serious claims

The Pennsylvania whistleblower, Carol Wessner, accused Aetna Better Health of Pennsylvania of shrinking its network of doctors for kids on Medicaid and then lying to the Pennsylvania Department of Health about it.

Aetna hired Wessner as a “quality management nurse consultant” in 2013. Her primary task was to investigate why such a high percentage of Aetna’s child patients were missing their Early and Periodic Screening, Diagnostic and Treatment appointments. The doctor visits, required by Medicaid since 1967, are intended to catch developmental and other health issues as early as possible.

Wessner claims that she discerned a pattern. Aetna officials contended that kids were missing appointments because providers were discriminating against them, but she found that time and again, those providers weren’t in Aetna’s network.

Wessner “never encountered an (Aetna pediatric doctor) who discriminated against children on (Aetna) Medicaid,” the suit says. “Rather, many of the (doctors) to whom children were assigned (i) were not contracted with (Aetna); (ii) were dead; (iii) were out of state; or (iv) did not see children at all.”

Many of the physicians to whom Aetna claimed to assign children wouldn’t be likely to pass even superficial scrutiny, Wessner said.

“… children, including two-year-old boys, were assigned to gynecologists, hospitalists and vascular surgeons,” the lawsuit says, referring to a provider group that Aetna listed as in its pediatric network. Aetna “also had wrong addresses, phone numbers and affiliations for the (primary care providers) at this site.”

Wessner also provided possible evidence that Aetna was deliberately shrinking its network while telling a different story to Pennsylvania Medicaid officials.

She said that on May 7, 2014, she was in a meeting with a Philadelphia public health official when the official was handed a note from Aetna. The company was notifying the city’s department of health that it was terminating its contracts with all eight of the agency’s City Health Centers, the suit says.

Yet by “February 2015 — almost a year later — (Aetna) still had 491 children enrolled with the department,” the lawsuit says. “Some were enrolled as recently as Feb. 1, 2015.”

Wessner claims that Philadelphia was far from the only agency in which Aetna terminated contracts with providers while continuing to tell state Medicaid officials that its child clients were enrolled with the agencies’ doctors. Her lawsuit says Aetna took similar actions with at least six other health systems, in some cases assigning children to doctors within the systems even after terminating their contracts.

In the case of the Reading Health Physicians Network, the lawsuit claims that in September 2016 — almost two years after Aetna had terminated its contract — the company still assigned 1,127 of its child clients to doctors there. Seven hundred thirty six of them hadn’t had their federally required diagnostic exams in at least a year, it said.

The lawsuit says money was the motive for all this.

Aetna “misrepresented its network adequacy by including providers (Aetna) knew were inaccessible in order to gain new Medicaid enrollees that would increase (Aetna’s) per-member/per-month payment from Medicaid.”


Wessner claims she was retaliated against for repeatedly flagging problems to her superiors, including Aetna Better Health of Pennsylvania CEO Jason Rottman.

She said her supervisor, Alice Jefferson, in 2015 told her to stop sending written reports and make them verbally instead. In 2016, Wessner was removed from her job investigating kids’ missed checkups. Then in 2018, she was terminated.

Regardless of the outcome of the case, it adds to questions about the companies hired as part of Ohio’s Medicaid reforms this year.

Aetna’s parent company, CVS, has long been accused of gouging Ohio Medicaid for prescription drugs — a charge the corporation denies. UnitedHealth has faced similar accusations and is being sued over fraud claims by Attorney General Dave Yost. Yet it was one of six giant corporations to be awarded huge managed-care contracts in this year’s procurement.

Yost in March sued another of those corporations, Centene, and it paid out $88 million in June to settle them.

When the Ohio Medicaid department undertook its procurement process, it set it up in a way that didn’t allow evaluators to consider previous bad acts by the companies applying. Now Mercer, the consultant that facilitated the process, won’t say whether any of the successful bidders are also its clients.