Understanding Aetna’s high profile lawsuits against OON providers

Understanding Aetna’s high profile lawsuits against OON providers

AVYM offers new Webinars to examine recently reported high profile Aetna lawsuits against out-of-network hospitals, surgical centers and doctors across the nation.  Lawsuits were filed in CA and TX, for allegedly not collecting deductible and co-insurance.  Simultaneously, additional lawsuits were filed in NJ and NY for over collecting (balance billing).

AVYM Webinars are designed to identify the litigation epidemic and propose practical strategies and solutions to avoid possible litigation through proactive and compliant practices.

While we are certainly NOT in a position to judge the merits of these allegations or predict any judicial outcome for the ongoing litigations, we must examine the Aetna lawsuits to find out what issues are avoidable and preventable.  These Aetna litigations represent a structural change by most payors in the reimbursement landscape for all out-of-network providers

Additionally, according to the Wall Street Journal on Feb 01, 2012, “Aetna Inc.’s earnings rose 73% as the health insurer continued to benefit from light medical costs amid a sluggish pace of patient visits to hospitals and doctors’ offices.” (http://online.wsj.com/article/SB10001424052970204740904577196551243915014.html)

According to the report from Crain’s New York Business on Feb. 07, 2012, Edward Neugebauer, Aetna’s head of litigation, is quoted as saying, “By spreading the cases out across the country, Aetna is using litigation ‘as a stepping-stone to open policy doors’ at the state level.”


LATEST NEWS: Aetna Accuses New York Doctors of Overcharging Patients

“Aetna made headlines in California last week when it sued seven California surgery centers for treating patients at out-of-network rates, charging $66,100 for a bunion repair. But in New York, Aetna quietly filed a lawsuit last October against New York doctors whose patients were socked with massive bills—in one case for more than $425,000.

“The two lawsuits, along with earlier ones filed in New Jersey and Texas, form a strategy by Aetna to combat what it sees as abusive out-of-network charges by providers, according to Crain’s Pulse.”

Also as stated in the report from the Crain’s New York Business on Feb. 07, 2012, Aetna complained about the provider’s failure to disclose the referral to out-of-network (OON) and OON UCR charges, and threats to balance bill patients for unpaid claims:

“The doctors did not clearly communicate the charges to Aetna patients, Aetna alleged […]

“Through a billing company, Business Dynamics, Hishmeh threatened to bill patients for the portions of the bills unpaid by Aetna, according to the lawsuit.”

At the same time as the NY and NJ cases, according to a Bloomberg Businessweek article on Feb 6, 2012, Aetna sued seven OON California surgery centers for allegedly not collecting or waiving co-insurance from the patients (http://www.businessweek.com/news/2012-02-06/bunion-repair-at-66-100-spurs-aetna-lawsuit-against-clinics.html):

“Bunion Repair at $66,100 Spurs Aetna Lawsuit Against Clinics”

“Feb. 3 (Bloomberg) — Aetna Inc. is suing seven California surgery centers for a billing system that it claims “recklessly subverts” health care delivery with charges of as much as $66,100 for a bunion repair.

The lawsuit seeks to stop the centers from waiving the co-insurance payments people are supposed to be charged when they use doctors or facilities that don’t have contracts with their insurers. By not requiring such payments for so-called out-of- network care, the centers illegally lured patients, and then billed Aetna up to 2,500 percent more than what the company pays its contracted providers for procedures, according to the suit.”

The court case info: Aetna Life Insurance Co. v. Bay Area Surgical Management LLC, File 02/02/2012, Case #: 112CV217943, The Superior Court of California, County of Santa Clara.

Aetna TX case info: AETNA HEALTH INC vs. SOFOLA, IFEOLUMIPO O (MD) (Case #: 2011-73949 / Court 152), Harris County, Texas.

“Providers are caught in a catch-22 situation; if they do not collect patient’s co-pays and deductibles, they may be subject to lawsuits as in the CA case.  On the other hand, if they collect patient’s co-pays and deductibles, they may be subject to lawsuits as in the NY and NJ cases.  It is a situation where providers are damned if they do and damned if they don’t.  Aetna may or may not prevail in court for these allegations, but we must look to why and how providers may or may not get sued” said Vincent Flores, President of YF Corporation, and a national expert on PPACA and ERISA appeals and compliance.

This new executive Webinar will discuss the following topics:

  1. Why and how the waiver of deductible and co-insurance may be questionable practice, subject to the payor’s legal challenges in court and SIU investigations; how to avoid them with compliant policies and practice.
  2. Compliant policies and practices for proper disclosures, for the patients to make informed decisions in exercising freedom of choice for utilization of OON providers, solely based on the quality and safety of the care and reputations of the providers.
  3. OIG: Fraud and abuse prevention brainstorming.  (http://oig.hhs.gov/compliance/provider-compliance-training/index.asp)
  4. DOL: About 77% of Insured Americans Purchased Out-Of-Network Coverage in Private Industry (BLS, NBS 2010, page 11 of 167): (http://avym.com/health-and-retirement-plan-provisions-in-private-industry-in-the-united-states/)
  5. PPACA & ERISA Compliant Appeals and litigation avoidance and/or support.
  6. DOL: PPACA & ERISA Claims Regulations Assistance and Complaints Webpage (https://www.askebsa.dol.gov/WebIntake/Home.aspx?submit=Submit+a+Complaint)

To find out more about PPACA Claims and Appeals Compliance Services from AVYM please click here.

Located in Los Angeles, CA, AVYM is a leading provider of services focusing entirely on the resolution of denied or disputed medical insurance claims by participating in the nation’s first ERISA PPACA Claims Appeals Certification program.  AVYM also offers free Webinars, basic and advanced educational seminars and on-site claims specialist certification programs for doctors, hospitals and commercial companies, as well as numerous pending national ERISA class action litigation support.



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