The clinics have joined with 60 individual physicians and several California medical associations in a lawsuit against Aetna, filed last week in Los Angeles County Superior Court. The plaintiffs allege that Aetna is preventing in-network physicians from referring members to out-of-network facilities, violating patient rights according to their insurance policies, which contain out-of-network benefits.
According to the report, the real issue at stake is one of cost. Aetna’s position in the lawsuit, according to the LA Times, is that when physicians refer patients for surgeries or tests to out-of-network facilities owned by the physicians themselves, they defeat the purpose of negotiating in-network contracts with the company.
According to the report, the insurers do not have an explanation for why they didn’t notice the alleged fraud on the part of Bay Area Surgical Management and stop it long ago — or why they paid inflated claims, as they are now suggesting. The report suggests that if Aetna and United have not taken on the responsibility of installing data programs to monitor claims effectively, they are not doing the work asked of them.
“If the insurers continue to perform this badly, who will pay the price?” Mr. Hiltzik wrote. “As taxpayers and policyholders, you will.”
