Out of network doctors GOUGING health insurance companies., page 1

Some of these charges are unbelievable and the insurance companies are forced to pay what these shysters demand because state laws require them to pay in a timely manner (to prevent the patient being billed) giving insurance companies little time to dispute outrageous charges.

Aetna got fed up with a few really obnoxious docs in (yech) New Jersey and is naming names in a lawsuit to try to get some of its money back.

Ultrasound at $59,490 Spurs Aetna Outrage in Suit Naming Doctors

Aetna Inc. (AET) is suing six New Jersey doctors over medical bills it calls “unconscionable,” including $56,980 for a bedside consultation and $59,490 for an ultrasound that typically costs $74.

The lawsuits could help determine what pricing limits insurers can impose on ”out-of-network” physicians who don’t have contracts with health plans that spell out how much a service or procedure can cost.

The most detailed complaint is against Benyamin Hannallah, a cardiologist at Jersey City Medical Center. Hannallah charged $59,490 for a heart ultrasound in April 2010 and was paid $47,592, the suit says. Aetna reimburses in-network doctors $74 for the procedure at Jersey City hospitals, Michener said.

Hannallah billed Aetna $56,980 last July for a consultation with a patient who wasn’t critically ill, a hospital visit that typically takes 25 minutes, according to the suit. The insurer refused coverage, and said Hannallah had asked for $220 for this type of consultation in 2007.

In April 2010, Aetna said, Hannallah asked for $54,600 for a heart catheterization, up from $5,500 for the same procedure in 2007. When the insurer gave him $2,000 -- a sum it deemed “usual and customary” for the procedure -- Hannallah complained, and Aetna paid in full to prevent him from billing the patient for the remainder, Michener said.

Bloomberg

The doctors say they need to charge extra to make up for the lack of referrals they would get if they were "in network" providers. I can see a little mark-up for that but, what these guys are doing is ridiculous.

Unfortunately, I wouldn't hope for much from these lawsuits; it seems the state and regulatory agencies tend to side with the doctors in these cases.

“These doctors can charge whatever they want,” Leibowitz said. “The challenge for the carriers is to come up with an agreeable, acceptable, unbiased judgment as to what a reasonable and customary reimbursement rate is.”
AMA Lawsuits

Aetna tried in 2007 to impose caps on some out-of-network payments, prompting doctor complaints to the New Jersey Department of Banking and Insurance. The agency sided with the doctors, fined the company $2.5 million, and ordered it to pay out-of-network practitioners enough so that patients wouldn’t be asked to pay balances other than co-pays.

In 2009, Aetna, UnitedHealth Group Inc. (UNH), Cigna Corp. (CI) and WellPoint Inc. (WLP) were accused by the New York attorney general of underpaying out-of-network physicians by manipulating a database used to calculate payments. They paid a total of $90 million in settlements without admitting wrongdoing. UnitedHealthcare agreed that year to pay $350 million to settle a lawsuit by the American Medical Association over the same issues. Similar AMA lawsuits against Aetna, Cigna and Wellpoint are pending.

The AMA has way too much power when dealing with the insurance industry. They seem to do everything in their power to lower the quality of care while causing prices to skyrocket.

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