PHILADELPHIA – The parent company of Lehigh Valley Health Network (LVHN) is suing Aetna over reimbursements tied to certain Medicare Advantage patients.<\/p>\n
Jefferson Health filed the lawsuit against the health insurer earlier this week in the U.S. District Court for the Eastern District of Pennsylvania.<\/p>\n
Also named as a plaintiff is\u00a0Lehigh Valley Physician Hospital Organization, Inc. (LVPHO), also known as Valley Preferred, a physician-hospital organization that is a partnership between Lehigh Valley Health Network and the Greater Lehigh Valley Independent Practice Association.<\/p>\n
LVHN joined Jefferson Health in 2024, but Valley Preferred remains a separate entity.<\/p>\n
The lawsuit alleges that Aetna is violating federal law with its new\u00a0Level of Severity Inpatient Payment Policy, which was implemented at the start of 2026.<\/p>\n
Specifically, Jefferson and LVPHO say Aetna is not following the standards of the Two Midnight Rule, which defines what inpatient services the Medicare program covers.<\/p>\n
The Two Midnight Rules boils down to inpatient care vs. outpatient care; inpatient admissions would generally be covered if the doctor expected the patient to require a hospital stay that crossed two midnights.<\/p>\n
The lawsuit alleges that Aetna is effectively creating a two-tiered rate structure by telling its Medicare Advantage members that it is covering the inpatient admission, while only paying hospitals for the equivalent of outpatient care.<\/p>\n
Aetna denies violating the Two Midnight Rule. In its explanation of the Level of Severity Inpatient Payment Policy, the company said, “the policy is a claims payment policy that determines reimbursement based on the severity level of the inpatient admission.”<\/p>\n
But it is Aetna that is determining whether an inpatient stay is medically necessary, which sometimes conflicts with a doctor’s assessment, the lawsuit alleges.<\/p>\n
Jefferson and LVPHO are asking the court to stop Aetna from implementing the policy without a contractual amendment.<\/p>\n
Other legal entanglements\u00a0<\/p>\n
LVHN and Aetna have squared off before.<\/p>\n
In 2022, prior to its affiliation with Jefferson, LVHN said it would drop Aetna as an in-network insurance provider.<\/p>\n
At the time, the health network said it was ending the relationship\u00a0because of unpaid bills dating back several years; it also accused Aetna of routinely denying and delaying claims.<\/p>\n
But the two sides were able to reach an agreement.<\/p>\n
LVHN is currently locked in a dispute with UnitedHealthcare (UHC).\u00a0<\/p>\n
The Medicare Advantage contract between LVHN and UHC was terminated on January 26, ending in-network access to LVHN providers for more than 5,400 UHC policyholders.<\/p>\n
LVHN patients with employer-sponsored UHC commercial plans will face the same reality on April 26, when that contract is scheduled to end.<\/p>\n
Those enrolled in the Veteran Affairs Community Care Network (VACCN) would also lose in-network coverage.<\/p>\n
According to an update posted on UHC’s website, the two sides are still negotiating.<\/p>\n
Jefferson Health clinicians remain in-network for patients with UnitedHealthcare coverage.<\/p>\n","protected":false},"excerpt":{"rendered":"PHILADELPHIA – The parent company of Lehigh Valley Health Network (LVHN) is suing Aetna over reimbursements tied to…\n","protected":false},"author":2,"featured_media":160655,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[10],"tags":[214,119,121,120,60,805,28,7446],"class_list":{"0":"post-160654","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-allentown","8":"tag-_homepage_top_stories","9":"tag-allentown","10":"tag-allentown-headlines","11":"tag-allentown-news","12":"tag-business","13":"tag-lehighvalley","14":"tag-pennsylvania","15":"tag-southeastern-pa"},"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/us-pa\/wp-json\/wp\/v2\/posts\/160654","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/us-pa\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/us-pa\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us-pa\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us-pa\/wp-json\/wp\/v2\/comments?post=160654"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/us-pa\/wp-json\/wp\/v2\/posts\/160654\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us-pa\/wp-json\/wp\/v2\/media\/160655"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/us-pa\/wp-json\/wp\/v2\/media?parent=160654"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us-pa\/wp-json\/wp\/v2\/categories?post=160654"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us-pa\/wp-json\/wp\/v2\/tags?post=160654"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}