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Aetna Sued for Systematically Denying Care to Patients

Respiratory Sleep Solutions, LLC (RSS), a wholly owned subsidiary of the Alliance Family of Companies, LLC (Alliance), has filed suit against Aetna seeking a declaratory judgment that restores patient access to needed in-home neurodiagnostic testing. The suit alleges that Aetna has systematically violated standard coding practices for RSS-provided in-home video electroencephalogram testing (VEEG), effectively preventing patients from accessing in-home neurological testing for epilepsy and other disorders.

"Aetna is lining its pockets by denying patients neurodiagnostic testing that is affordable, accessible, convenient and effective," said Conor Butts, Chief Operating Officer of RSS.

The number of adults and children in the U.S. who are diagnosed with epilepsy is growing, and in-home neurodiagnostic testing services, such as VEEG, are increasingly essential. In-home VEEG services are approximately one-sixth of the cost of in-patient hospital testing and allow patients to avoid missing work and expensive childcare arrangements. Because in-home testing ensures no disruption to patients' day-to-day lives, some physicians view it as more effective than testing that occurs in an artificial hospital environment. Patients can also be tested and obtain results in as little as ten days, compared to a wait time of up to three months or longer to have the testing completed in a hospital.

In total, more than 3.4 million individuals in the U.S.—including more than 470,000 children—are living with epilepsy. As service needs expands, the demand for in-home diagnostic testing services has grown.

Medicaid and Medicare have covered in-home testing for more than a decade, and until April of 2017 even Aetna covered this critical service.

"At a time when our healthcare system is under intense stress and in desperate need of creative solutions that expand rather than restrict access to care, Aetna's actions are not only misguided, but harmful to vulnerable patients." said Jeremy Slater, MD, Chief Medical Officer of Alliance who received his medical degree from the University of Pittsburgh School of Medicine and served as the Director of the Texas Comprehensive Epilepsy Program from 2004 to 2017. "This diagnostic service is less expensive, more accessible and is as effective in appropriately selected patients. All we ask is that our patients can access the care that they need, and that they can do so in a timely manner."

The lawsuit, filed in the District Court of Dallas County, Texas alleges that Aetna's payment policy has refused to follow established Current Procedural Terminology (CPT) codes established by the American Medical Association (AMA) to describe and determine proper reimbursement for services provided. It further alleges that Aetna has unilaterally mis-coded in-home testing provided by RSS to Aetna's patients, which contravenes the intent of the AMA when it wrote the procedures defined in each of the CPT codes.

As a result of Aetna's practices, a growing number of individuals have been denied access to in-home VEEG testing. Additionally, Aetna has denied RSS proper reimbursement for its services. The lawsuit seeks to force Aetna to acknowledge the proper coding for RSS' services pursuant to the EEG CPT Codes as written by the AMA, and to reimburse RSS for its services under the CPT Code which accurately reflects its services.

Alliance is a leading provider of neurodiagnostic testing in North America, with coverage and resources in 35 states. Its transformative health care solutions are focused on innovation in the delivery of healthcare services that enable physicians to create treatment plans which improve patients' quality of life.

via bizjournals

#aetna #healthinsurance

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