The Fourth Circuit U.S. Court of Appeals ruled recently that a class action case could proceed against Aetna and Optum for using so-called “dummy” billing codes whereby Aetna told Optum-owned providers to “bury” charges for these miscellaneous billing codes into the billed charges for the self-funded health plan operated by Mars Inc. The plaintiff, Sandra Peters, a member of the Mars plan, launched the class action that was originally stopped at the lower court level, but revived today.
The case is a cautionary tale for self-funded employers. It’s just not good enough for plan fiduciaries to trust that carriers (even acting only as ASOs), PBMs and other plan service providers are looking out for the interests of plan sponsors and their beneficiaries. Such companies are answerable to their Wall Street shareholders, not the patients and employers paying the bills. AllBetter Health can bring accountability and transparency back to a self-funded plan, mitigate ERISA liability for employers and physical and financial harm to patients.