Aetna is being sued by Vanguard Aesthetic and Plastic Surgery for an alleged "unreasonably low" reimbursement rate for services from the Fort Lauderdale, Fla.-based provider.
Court documents filed March 29 in the U.S. District Court Southern District of Florida claim Aetna entered a contract with Vanguard by granting an in-network exception for all care for a particular patient.
The patient received double mastectomies with immediate implant reconstruction in April 2019, which Aetna preauthorized, and an emergency follow-up surgery in September, according to the court documents. The surgeons were out of network, but Aetna granted the provider an in-network exception for all care because its staff were the only individuals available in the region that could perform the specific surgery.
Vanguard charged Aetna $301,069 for the three surgeries, of which Aetna paid $11,358.73, or 3.7 percent of the claim.
In the lawsuit, Vanguard said it never accepted a discounted rate and claimed Aetna cited a "negotiated rate" as reasoning for the small reimbursement.
Vanguard is seeking full reimbursement for the original claim and alleges the patient is entitled to monetary damages from Aetna. Vanguard is also requesting a trial by jury.