Thousands of doctors in California are suing the health insurance company Aetna claiming the company routinely denies patients access to out-of-network doctors even when the patient has purchased a policy giving them the right to choose providers.
The lawsuit, filed in the Los Angeles County Superior Court, accuses Aetna of threatening patients with denial of coverage if their members visit doctors outside the Aetna network of providers, and of threatening doctors with having their Aetna contracts terminated if they refer patients outside the network.
The lawsuit was brought by the Los Angeles County Medical Association, California Medical Association and a coalition of health care organizations and providers.
Aetna claims the suit is in retaliation for a suit filed by Aetna in February claiming several California providers, including Bay Area Surgical Management and seven ancillary facilities, sent Aetna members to BASM without revealing that physicians had an ownership interest in the facility or were getting paid by BASM for their referrals.
"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," Cynthia Michener, a spokeswoman for Aetna, said in an email. "This is a countersuit disguised as a class-action lawsuit."
The South Bay surgery group denied the allegations in Aetna's $20 million suit, reported by this newspaper in June.
The allegations were inaccurate and represent an attempt to force the his company to sign a contract with very low reimbursement rates for patient care, a group spokesman said then.
"It's a strong-arm tactic," said Bobby Sarnevesht of Surgical Management. "They think if they come at us, all at once, we'll be bullied into signing an unfavorable contract."
The company, which manages outpatient surgical centers, says it gets paid just a fraction of what insurers pay to surgery centers affiliated with hospitals like Stanford or El Camino in Mountain View.
Michener said Aetna would "continue to pursue medical providers whose charges are so grossly out of line."
She cited as examples facilities and doctors who have charged $73,536 for a kidney stone fragmentation when an average in-network charge would be around $7,612. Or those that have charged $37,572 for a knee procedure that would cost about $10,500 with an in-network physician.
Michener was not immediately able to say what the average cost of these procedures would have been in out-of-network facilities that are not being sued by Aetna.
Aetna's response was an attempt to divert attention, the Los Angeles County Medical Association said in a prepared statement issued Tuesday.
"Aetna is misrepresenting the nature of the lawsuit filed today to divert attention from the real issues and those are Aetna's abusive policies and retaliatory tactics in pursuit of higher profits. Aetna is threatening the quality of care patients receive -- putting its profits ahead of patients."
The lawsuit brought by the physicians accuses Aetna of false advertising, breach of contract, unfair business practices, and both intentional and negligent interference with health care providers.
The Bay Area News Group contributed to this report.