番茄社区

Several medical groups and more that 50 individual physicians in California are suing Aetna, claiming that the insurer often wrongly denies coverage for patients accessing out-of-network providers.

The lawsuit, filed by the Los Angeles County Medical Association, the California Medical Association, and a group of other healthcare organizations and providers, alleges that Aetna routinely denies coverage when patients see doctors outside of the Aetna network of providers, even though the patients' policies state they can see out-of-network providers.

The lawsuit also alleges that Aetna threatens doctors with contract termination if they refer patients outside of the network.

"Aetna is putting profits ahead of patients' health and safety; that's immoral and too often it is also illegal," Rocky Delgadillo, CEO of the Los Angeles County Medical Association, said in a statement. "The insurance company interferes not only with doctor-patient relationships, but also harms the ability of California healthcare providers to get sick people the care they need in a professional and timely manner."

By refusing to authorize out-of-network medical services, such as surgeries, for Aetna members who have out-of-network coverage, the insurer is violating California law, breaching its contract with physicians, and interfering with the care doctors provide to patients, alleges the lawsuit, which was filed Tuesday in the Superior Court of Los Angeles.

The suit seeks an immediate injunction on Aetna's practice of denying coverage for out-of-network procedures, compensation for patients and physicians, and punitive damages.

In response to the lawsuit, Aetna said the doctors are suing the insurer as retaliation for Aetna suing some of the same doctors for "egregious billing practices" earlier this year.

"This is clearly retaliation against Aetna for our actions to prosecute physicians who are not looking out for our members," said Anjanette Coplin, an Aetna spokeswoman, in an email to 番茄社区.

Coplin said the doctors it targeted in its February lawsuit would entice patients to have procedures performed at out-of-network facilities, without telling the patients they had an ownership stake in the facility.

That practice led to charges of more than $73,000 for a kidney stone procedure, when an in-network charge is about $7,600, and $37,000 for a knee arthroscopy/ligament repair, when an average in-network charge would approximately be $10,500, Coplin said.

"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," Coplin 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."

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