A recently unsealed whistleblower lawsuit accuses CVS Health Corp.’s Aetna of defrauding the Commonwealth of Pennsylvania and the federal Medicaid program by knowingly misrepresenting the number of pediatricians in Aetna’s Medicaid network. While the outcome of the suit is far from certain, and the Dept. of Justice opted not to intervene in the matter, legal experts say the case may have merit — and Medicaid insiders say that Aetna’s reputation may take a hit.

Carol Wessner, a nurse and former Early and Periodic Screening, Diagnostic and Treatment consultant for Aetna, alleges in a recently unsealed lawsuit that pediatric primary care was practically inaccessible to Aetna’s Medicaid members because of its incorrect provider directory. The insurer covered 265,868 Medicaid lives in 2020 under the Aetna Better Health of Pennsylvania brand, according to Pennsylvania’s Dept. of Human Services (DHS). Wessner’s suit claims that, in fraudulently exaggerating the amount of pediatric primary care doctors and the number of patients they served, Aetna was able to pocket an excessive margin of its capitated payments from the Medicaid program.

In a court filing, Wessner also claims that she made Aetna executives including Aetna Better Health CEO Jason Rottman and Director of Quality Management Alice Jefferson aware of the network’s shortcomings — and that they retaliated against Wessner by terminating her. In 2017, Wessner first filed a qui tam whistleblower complaint under the False Claims Act of 1863, which means that she would be entitled to a large portion of any settlement or damages Aetna might pay. During that time, federal prosecutors considered whether to join the case against Aetna.

Unlock the full version of this article by subscribing.

Log in | Learn More