By MATTHEW STURDEVANT, email@example.com
The Hartford Courant
6:02 PM EDT, July 5, 2012
Aetna is being sued by thousands of doctors who say the health insurer won't allow patients to get medical treatment from out-of-network doctors even though those patients have health plans that allow them to pick any clinician.
The lawsuit filed Tuesday in Los Angeles County Superior Court says Aetna has threatened patients with denial of coverage for going to out-of-network clinicians. The lawsuit also accuses Aetna of threatening to end contracts with doctors if they refer patients to clinicians outside Aetna's network.
"Aetna is putting profits ahead of patient's health and safety; that's immoral and too often it is also illegal," said Rocky Delgadillo, CEO of the nonprofit Los Angeles County Medical Association and also the former Los Angeles city attorney. "The insurance company interferes not only with doctor-patient relationships, but also harms the ability of California health care providers to get sick people the care they need in a professional and timely manner."
The lawsuit was filed by the Los Angeles County Medical Association, representing 6,500 members; California Medical Association, representing 35,000 members; and other groups of clinicians.
The Hartford-based health insurer says the lawsuit is retaliation for a different lawsuit Aetna filed in February that accuses a number of California medical facilities of scheming to steer patients to clinics that charge more than nine times the in-network rates for medical procedures.
Aetna's lawsuit against some California providers, including Bay Area Surgical Management (BASM) and seven related facilities, says clinics allegedly referred Aetna members to BASM though the referring doctors didn't disclose to their patients that they had part ownership in BASM and were paid for sending patients there.
Patients were enticed to go to the BASM clinics because it was made less expensive, Aetna says in its lawsuit. BASM waived co-pays and deductibles that are ordinarily higher at out-of-network facilities, Aetna says in its lawsuit. The insurer was left paying many times more for the procedure than it would have at an in-network clinic.
Aetna spokeswoman Cynthia Michener said in-network doctors' average price for a kidney-stone-fragmentation procedure is $7,612 compared with $73,526 if done by Bay Area Surgical Management. A circumcision that costs Aetna $3,619 for in-network doctors was priced at $13,662 at Bay Area Surgical Management, the company said. A colonoscopy that ordinarily costs $2,555 at an in-network physician is $5,760 at Bay Area Surgical, according to Aetna.
"Doctors who entice patients to have procedures performed at out-of-network facilities that they own without the patient's knowledge are putting profits over their patients," Michener said. "The wildly-inflated bills of these facilities drive up the out-of-pocket costs for unwitting patients and needlessly add to premium costs for everyone."
The doctors say it is Aetna that has falsely advertised, breached its contracts, conducted unfair business practices and has interfered with health care providers.
"Aetna has given us no choice," said Delgadillo. "Aetna's assault on patient rights and its abandonment of its promises — its contractual responsibility to patients, doctors and employers — has to be stopped."
The doctors are asking for an end to Aetna's practices, compensation for patients and doctors, and punitive damages.
"We find it troubling that the California Medical Association and other county medical associations would support this type of egregious behavior from physicians," Michener said. "Aetna has contacted regulators, such as the California Medical Board and the California Department of Insurance, as well as legislators over the past three years in an effort to voice our concerns about these types of business practices from physicians."