Violation Tracker Individual Record
As a result of provider complaints, the Department learned that starting in or about June 2007, Aetna paid certain out-of-network claims at a rate based on 125% of Medicare (75% of Medicare in the case of lab fees and durable medical equipment). Aetna sent certain providers a letter stating the payment represented Aetna's determination of a fair payment and that additional reimbursement would not be considered. Aetna applied this claims practice for services such as emergency care, services provided by nonparticipating providers during an admission to a network hospital, and services rendered as the result of a referral or authorization by Aetna. In such cases, Aetna knew that its payment obligations exceeded what it paid and represented in its letters. Aetna stated that a total of 130 providers were issued such a letter, with the first issued on or about June 8, 2007.