Violation Tracker Individual Record

Aetna Health, Inc.
Current Parent Company: 
CVS Health
July 23, 2007
Offense Group: 
consumer-protection-related offenses
Primary Offense: 
insurance violation
Violation Description: 

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.

Level of Government: 
Action Type: 
agency action
New Jersey Department of Banking & Insurance
Civil or Criminal Case: 
Facility State: 
New Jersey
HQ Country of Parent: 
HQ State of Parent: 
Rhode Island
Ownership Structure of Parent: 
publicly traded
Major Industry of Parent: 
Specific Industry of Parent: 
Source Notes: 
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Parent company note: 
Parent-subsidiary relationship is current as of the most recent revision listed in the Update Log.