3 Pennsylvania health systems sue Aetna for breach of contract

A group of three Pennsylvania health systems has sued Aetna, alleging the insurer subtracted the cost of supplemental benefits from money intended for patient care. 

Warrendale, Pa.-based Bridges Health Partners filed a lawsuit April 15, alleging Aetna had breached its contract with the integrated network. 

Bridges Health Partners is made up of three Western Pennsylvania health systems and a physician group. The clinically integrated network includes eight hospital campuses and over 1,000 employed or affiliated physicians. 

The group entered a value-based contract with Aetna in 2019 and renewed the contract in 2023, according to court documents. Under the contract, Aetna pays Bridges Health incentives for meeting cost targets and for meeting agreed-upon quality metrics. 

Bridges Health Partners alleged Aetna subtracted the cost of supplemental benefits offered to members from the payments it owed the care network. In the complaint, the system alleged Aetna deducted nearly $4 million in medical cost fund expenses for Bridges for supplemental programs, including over-the-counter benefits, fitness memberships and meal delivery. 

In a news release, Robert Zimmerman, MD, Bridges Health Partners president and chief medical officer, said the incentives are good programs but should not be paid for by Bridges. 

"If we have to pay for the incentives, we cannot provide cost-saving, patient-centered care. It's egregious manipulation but also a breach of our contract with Aetna," Dr. Zimmerman said. 

Bridges Health also alleged Aetna was funneling money back to parent company CVS Health by providing members with gift cards and over- the-counter benefits that can only be used at CVS pharmacies and called the supplemental programs "marketing expenses" designed to attract more members. 

The clinically integrated network requested a judge issue an injunction requiring Aetna to abide by the terms of its contract and reimbursement of funds and legal fees. 

Aetna declined to comment to Becker's. 

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