Correction: An earlier version of this article misstated the federal government's involvement. The federal government declined to intervene in this lawsuit, though the government has requested the court solicit written consent from the U.S. before the case is dismissed, settled or discontinued.
Aetna defrauded the government by doctoring its provider network to secure lucrative Medicaid contracts in the state of Pennsylvania, according to a lawsuit unsealed Tuesday in federal court.
Carol Wessner, a former employee and nurse, alleges that she discovered Aetna's pediatric network in Pennsylvania was inadequate per the terms of the contract with the state. She alerted her supervisors and was ultimately terminated because of it, she alleges in the whistleblower suit filed in January.
The federal government declined to join the lawsuit as a plaintiff but did request the court solicit written consent from the U.S. before the case is dismissed, settled or discontinued.
In a statement, Aetna said it "is pleased that after reviewing all of the evidence, the government chose not to participate in the lawsuit. Aetna denies the allegations in the complaint, and intends to vigorously defend itself should the relator choose to move forward with her non-intervened complaint."
In her role, Wessner was responsible for making sure pediatric patients were receiving timely screenings and services. When Wessner was hired in May 2013, she noticed Aetna's screening rates were far lower than the state average.
It was her job to find out why.
Wessner used claims data to isolate which providers had low annual visit rates. She started calling these providers to figure out the reason behind the low rate.
She then found that many Aetna listed as in network either did not have contracts, were not pediatric physicians, were out of state, retired or dead.
Wessner discovered that "tens of thousands of children were assigned to [primary care providers] that had no relationship whatsoever to [Aetna] despite Defendants' representations to the government that all were in network," the suit alleges.
In an email to a superior, one of the two individual defendants, Aetna Better Health of Pennsylvania CEO Jason Rottman, Wessner said children were being assigned not to pediatric primary care physicians but to gynecologists, including infants and males as well as to neurologists and pain management specialists.
Falsifying the network is what allowed Aetna to win Medicaid contracts in 2010 and 2014, Wessner alleges. Aetna would not have secured those contracts otherwise.
Without an adequate network, it decreased the amount of services Aetna had to pay for, yet Aetna continued to receive a payment each month for every member it covered in Pennsylvania.
Aetna serves about 180,000 Medicaid members in Pennsylvania and half are pediatric patients, according to the suit.
After alerting her supervisors to the issue, Wessner was moved to a different role and was ultimately terminated in 2018.
Alice Jefferson, Wessner's immediate supervisor, was listed in the suit along with Rottman.
Editor's note: The story has been updated with a statement from Aetna