In 2007, cardiologist Benyamin Hannallah accused of $220 to assess patients admitted to hospital where he worked, Jersey City Medical Center, across the River from New York. He then opened his own firm and raised its fees for the consultation of bedside of 25 minutes for $56,980, according to a lawsuit filed by Aetna (AET). The health insurer continues Hannallah and five other doctors in New Jersey to load what Aetna calls "unacceptable" expenses to treat patients admitted in four hospitals in New Jersey.
The prosecution could help determine what price limit insurers may impose on the out-of-network doctors, who do not have contracts with plans of health that define how a service or procedure may listen. "This is the surprise guest which comes in your room hospital and invoices then you and your health plan for the outrageous, undisclosed amounts," said j. Edward Neugebauer, head of the Aetna of the dispute.
Complaints provide an overview sums doctors earn the insurer and the enormous changes how different physicians Bill and receive the same services. Hannallah-billed $59,490 for cardiac ultrasound, which earns physicians of in the network of the Aetna in Jersey City $74, said spokeswoman Cynthia Michener Aetna. Another defendant, obstetrician Waleed Abdelghani, accused of $30 000 for a caesarean, or more than 10 times costs network Aetna citations, Aetna claims. "If these charges are accurate, the consumers and buyers should be outraged," said David Lansky, Chairman of the Group of companies in the Pacific on health in San Francisco, a coalition of buyers of health insurance which includes Chevron (CLC), Walt Disney (DIS) and General Electric (GE). Lawyers for doctors refused to comment on the charges specific combinations and said their clients did nothing wrong.
Aetna tried in 2007 to impose ceilings for certain payments out of the network, which has prompted complaints from New Jersey banks and the insurance Dept physicians. The Agency receives the insurer fined $ 2.5 million for violating consumer protection laws by failing to pay enough for HMO patients and ordered him to pay out-of-network practitioners enough that patients would be called for or their insurance.
In 2009, Aetna, UnitedHealth Group (UNH), Cigna (CI) and WellPoint (WLP) were charged by the Attorney General of New York for underpaying out-of-network physicians by manipulating a database used to calculate payments. They pay a total of $ 90 million in settlements without fault admission. UnitedHealth, even once without admitting wrongdoing, agreed this year to pay $ 350 million to settle an action by the American Medical Assn.. the same issues. WADA against Aetna, Cigna, and WellPoint similar lawsuits are pending.
Aetna, filed in the eight months, prosecution said the defendants violated the New Jersey State Board of Medical Examiners against fresh excessive rules and seek triple damages under the laws of the State against filing false insurance fraud or misleading claims. Cardiologist Hannallah loaded $ 59,490 for cardiac ultrasound in April 2010 and was paid $47,592, the suit said. In April 2010, Hannallah asked for $54,600 for cardiac catheterization, Aetna said, more than $5,500 for the same procedure in 2007. When the insurer gave him $ 2,000 - a sum he considered "usual and routine" procedure - Hannallah complained. Aetna paid in full to prevent it from billing the patient for the rest, said Michener. The insurer said that it released Hannallah a total of $ 3.2 million in 2008 and 2009, of $529,503 in the period of two years before.
Robert Conroy, Hannallah lawyer, said the Aetna of some of the costs description in his complaint are false or misleading. Some cited costs been authorized in advance by the insurer, he said, and some have been negotiated between Hannallah and a third Aetna representative.
In its action against Deepak Srinivasan, a cardiologist of Hackensack University Medical Center, Aetna says that the doctor raised its fees for cardiac catheterizations $ 18,720 in 2007 of $3,000 in 2006. Aetna income increased by $ 2.5 million in 2008, $155,310 in 2006, the suit said. George Frino, Srinivasan Attorney, said that aetna has agreed to its schedule as a practitioner outside of the network in 2007. Srinivasan has filed a countersuit alleging that Aetna, paying him does what it must, violation of laws governing plans for group health and committed mail fraud in its rebate practices. The Aetna Michener calls the counterclaim of the Srinivasan "without foundation".
Abdelghani, who practice also in Hackensack n.j. hospital has increased his charge by caesarean section at $30,000, in 2009, $ 3,000 in 2008, the combination alleges. Aetna paid the fee of $30 000 full-time "many" in 2009, said Michener. In the network of doctors in the region to receive $2,655 for the operation, function Aetna. Income of the Abdelghani Aetna passed 76,173 $ in 2007 to 5.1 million in 2010, the company said.
Abdelghani Attorney, Charles Gormally, challenged the figures of the Aetna and explains the practical paid insurer of Abdelghani 5.8 million over a period of three years. Aetna charged practice almost 13 million dollars over three years, with some outstanding procedures in all, said.
The bottom line: The Aetna against expensive out-of-network charges legal campaign is just the latest attempt by insurers to prevent the increase in health spending.
Waldman is a journalist for Bloomberg News.
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