{"id":8395,"date":"2026-04-11T15:38:26","date_gmt":"2026-04-11T15:38:26","guid":{"rendered":"https:\/\/globalnewstoday.uk\/index.php\/2026\/04\/11\/jefferson-health-sues-aetna-over-new-medicare-advantage-payment-policy-glenside-local\/"},"modified":"2026-04-11T15:38:26","modified_gmt":"2026-04-11T15:38:26","slug":"jefferson-health-sues-aetna-over-new-medicare-advantage-payment-policy-glenside-local","status":"publish","type":"post","link":"https:\/\/globalnewstoday.uk\/index.php\/2026\/04\/11\/jefferson-health-sues-aetna-over-new-medicare-advantage-payment-policy-glenside-local\/","title":{"rendered":"Jefferson Health sues Aetna over new Medicare Advantage payment policy – Glenside Local"},"content":{"rendered":"

April 11th, 2026 | By Ryan Genova
Jefferson Health filed a lawsuit against insurer\u00a0Aetna this week over a new \u201cdowncoding\u201d policy regarding inpatient admissions for Medicare Advantage beneficiaries.
The health system claims that the policy violates federal law and reduces payments for hospital stays for Medicare Advantage patients that Aetna decides aren\u2019t sick enough to qualify for full payment. Jefferson Health also claims that Aetna failed to comply with the terms of their agreement.
Jefferson is asking a judge to stop Aetna from implementing the policy.
According to Healthcare Dive<\/a>, <\/em>Aetna says the policy is meant to more quickly approve payment for inpatient hospital stays and rejected Jefferson\u2019s claims, saying its policies \u201ccomply with all applicable federal law and regulations and with the terms of our provider contracts.\u201d
From their coverage: <\/p>\n

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Under the policy, Aetna will approve urgent inpatient hospital admissions for MA beneficiaries who stay between one and four midnights without reviewing the claim for medical necessity,\u00a0but it will\u00a0pay hospitals at a lower rate comparable to an observation stay<\/a>. Aetna will only pay the negotiated inpatient rate if it finds the claim meets internal guidelines. Stays lasting five midnights or more will be paid at the higher rate.<\/p>\n

In its lawsuit, Jefferson says the policy violates Medicare\u2019s two-midnight rule, which determines coverage for inpatient and observational stays. It also violates federal policy that requires MA plans to cover all medically necessary services that traditional Medicare covers, according to the lawsuit. <\/p><\/blockquote>\n

Under the policy, Aetna will approve urgent inpatient hospital admissions for MA beneficiaries who stay between one and four midnights without reviewing the claim for medical necessity,\u00a0but it will\u00a0pay hospitals at a lower rate comparable to an observation stay<\/a>. Aetna will only pay the negotiated inpatient rate if it finds the claim meets internal guidelines. Stays lasting five midnights or more will be paid at the higher rate.<\/p>\n

In its lawsuit, Jefferson says the policy violates Medicare\u2019s two-midnight rule, which determines coverage for inpatient and observational stays. It also violates federal policy that requires MA plans to cover all medically necessary services that traditional Medicare covers, according to the lawsuit.
\u201cAetna is able to tell its Medicare Advantage members (and CMS) that it is \u2018covering\u2019\u00a0the inpatient admission, while simultaneously paying the Hospitals for the equivalent of outpatient observation care,\u201d the lawsuit says.
\u201cAetna\u2019s policy shifts costs onto providers through unilateral payment changes,\u201d Jeffrey Price, Jefferson\u2019s chief managed-care and payer-relations officer, said in a statement. \u201cFederal law is clear about what qualifies as inpatient care, and payment policies should not undermine that standard or create confusion that pulls clinical teams away from patient care.”
For all the latest news, follow us on Facebook<\/a> or sign up for Glenside Local\u2019s \u201cDaily Buzz\u201d newsletter here<\/a>.<\/strong> \t\t<\/p>\n

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source<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

April 11th, 2026 | By Ryan GenovaJefferson Health filed a lawsuit against insurer\u00a0Aetna this week over a new \u201cdowncoding\u201d policy regarding inpatient admissions for Medicare Advantage beneficiaries. The health system claims that the policy violates federal law and reduces payments for hospital stays for Medicare Advantage patients that Aetna decides aren\u2019t sick enough to qualify […]<\/p>\n","protected":false},"author":1,"featured_media":8396,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[7],"tags":[],"class_list":{"0":"post-8395","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-politics"},"_links":{"self":[{"href":"https:\/\/globalnewstoday.uk\/index.php\/wp-json\/wp\/v2\/posts\/8395","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/globalnewstoday.uk\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/globalnewstoday.uk\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/globalnewstoday.uk\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/globalnewstoday.uk\/index.php\/wp-json\/wp\/v2\/comments?post=8395"}],"version-history":[{"count":0,"href":"https:\/\/globalnewstoday.uk\/index.php\/wp-json\/wp\/v2\/posts\/8395\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/globalnewstoday.uk\/index.php\/wp-json\/wp\/v2\/media\/8396"}],"wp:attachment":[{"href":"https:\/\/globalnewstoday.uk\/index.php\/wp-json\/wp\/v2\/media?parent=8395"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/globalnewstoday.uk\/index.php\/wp-json\/wp\/v2\/categories?post=8395"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/globalnewstoday.uk\/index.php\/wp-json\/wp\/v2\/tags?post=8395"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}