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Doctors v Aetna, What’s Happening in California?
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Apparently, thousands of doctors in California are suing the health insurance company Aetna Inc claiming that the company regularly attempts to deny patients any access to out-of-network doctors even if the patient purchases a policy that permits them to choose their own health providers. The lawsuit has been filed in the Los Angeles County Superior Court and accuses that Aetna threatened patients with denial of coverage if they visit doctors who are not part of Aetna’s network of healthcare providers. The lawsuit also alleged that the company threatens doctors within its network of terminating their contracts if they refer patients to doctors outside the Aetna network.

Healthcare seems to be simmering. Mandatory insurance, and now mandatory network.

The lawsuit, brought the Los Angeles County Medical Association, the California Medical Association and a coalition of health care organizations and providers accuse Aetna of false advertising, breach of contract, unfair business practices, and both negligent and intentional interference in the work of healthcare providers. The lawsuit seeks an immediate injunction to stop such practices and provide compensation for patients and physicians with punitive damages.

  
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The lawsuit stated, “Despite making tens of millions of dollars selling policies with out-of-network benefits, Aetna has engaged in a campaign to retaliate against its members who attempt to use their out-of-network benefits, and the physicians who refer these members to out-of-network providers.”

On their part, Aetna maintains that the lawsuit is in retaliation of steps taken by the company against some healthcare providers who charged exorbitant rates. Cynthia Michener, a spokeswoman for Aetna said, “We have sued some of these same doctors and surgery centers named in the suit for their egregious billing practices in February of this year … This is a countersuit disguised as a class action lawsuit.”

Cynthia Michener, further cited examples in support of the actions of Aetna, which if proved true, is quite revealing. For example, she cited doctors who charged $73,536 for a kidney stone fragmentation when Aetna’s average within network charge was around $7612. She further cited examples where a knee procedure which costs about $10,500 within the Aetna network was charged $37,572 by an out of network physician.

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The lawsuit filed by Aetna in February claims that several California providers, including Bay Area Surgical Management and seven ancillary facilities sent Aetna members to BASM without disclosing that the physicians had ownership interest in the facility, or that they were getting paid by BASM for the referrals.





 

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