Health

Aetna, Optum ‘pseudocode’ lawsuit revived


Aetna and OptumHealth face another round of legal battles with patients who accuse the companies of seeking to charge more share by masquerading as medical expenses.

Judge Martin Reidinger of the United States District Court for the Western District of North Carolina certified a class action on Monday that included more than 87,700 people and nearly 2,000 health plans. According to the plaintiffs, CVS Health subsidiary Aetna and UnitedHealth Group subsidiary Optum breached their fiduciary obligations under the Employee Retirement Income Security Act of 1974 through payment methods misleading increases costs for policyholders and program sponsors.

The original plaintiff, Sandra Peters, who is retired, sued the companies in 2015 after her out-of-pocket physiotherapy costs doubled under her employer-sponsored Aetna plan. Optum was included in the lawsuit because it built Aetna’s network of providers of physical therapists and chiropractors.

During the discovery process, Aetna and Optum passed emails saying the companies had agreed to develop “pseudocodes” for the purpose of “burying fees” and converting administrative fees into medical expenses.

Aetna and Optum did not respond to requests for interviews.

In 2019, Reidinger sided with the defendants, concluding that Peters and the employer who funded her plan had saved money under Aetna’s policy, so the insurer and Optum weren’t breaking the law. . A federal appeals court overturned that decision in 2021, and the Supreme Court confirmed that ruling and referred the case to district court last year.

Based on the arguments of the higher courts, Reidinger rejected Optum’s offer to dismiss and certify the class on Monday. The judge also denied Peters’ request that the class receive probable relief and order while the case was pending.

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