Kraft Panel Sues Aetna for Health Plan Missteps, Claims Data

Kraft Heinz Co.'s employee benefits committee accused Aetna Life Insurance Co. of mismanaging its health and dental plans by pocketing undisclosed fees and paying millions of dollars worth of claims that shouldn’t have been approved.

Aetna, which served as the third-party claims administrator Kraft’s plans, approved false, fraudulent, and improper claims, including thousands of duplicative claims, through an automatic process that involved no human review, Kraft said. Kraft asked Aetna to turn over its claims data in 2021 so it could investigate these matters, and the company responded by producing only “self-selected” and incomplete data, Kraft alleged.

Aetna is also accused of taking undisclosed fees from the Kraft plan under “false pretenses.” According to Kraft, Aetna uses a series of “repricing companies” that try to induce medical providers into accepting lower amounts so that Aetna can pocket the difference between what the Kraft plan paid and what the provider accepted.

Kraft says Aetna uses “less rigorous” standards when assessing claims for self-funded plans—those in which the sponsoring employer pays the medical bills—than it uses when administering fully-insured plans, in which Aetna is on the hook for paying bills. Aetna devotes most of its fraud detection efforts toward its fully-insured plans, leaving self-funded plans like Kraft’s in a worse financial position, according to the lawsuit.

The lawsuit, filed June 30 in the US District Court for the Eastern District of Texas, accuses Aetna of trying to conceal these misdeeds by refusing to turn over claims data that would allow Kraft to appropriately assess the company’s performance.

The lawsuit echoes a recent case filed against Anthem Blue Cross & Blue Shield, which also seeks to force the disclosure of a health plan’s claims data.

Aetna didn’t immediately respond to a request for comment.

McKool Smith PC represents Kraft.

The case is Kraft Heinz Co. Emp. Benefits Admin. Bd. v. Aetna Life Ins. Co., E.D. Tex., No. 2:23-cv-00317, complaint 6/30/23.