Aetna (NYSE: AET) is suing six New Jersey doctors over "unconscionable" and "excessive" medical bills in a lawsuit that could help determine what pricing limits insurers can impose on out-of-network doctors, reports Bloomberg.
In one case, Aetna claims it paid a neurosurgery practice $3.9 million more than it was entitled to receive. The practice also billed a patient $116,000, even after Aetna had provided payment in full, according to The Record.
The insurer also claims a cardiologist at Hackensack University Medical Center increased his charges more than sixfold for catheterizations, from $3,000 to $18,720. The fees drove his income from Aetna up from $155,310 in 2006 to $2.5 million in 2008.
Aetna's 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. Aetna reimburses in-network doctors $74 for the procedure at Jersey City hospitals. The amount Hannallah requested for heart ultrasounds quadrupled between 2009 and 2010, and his price for cardiac-stress tests rose more than tenfold to $15,850 between 2008 and 2010, notes Bloomberg.
Hannallah's lawyer said the fees in Aetna's complaint are "false and/or misleading" because some were pre-approved and others were negotiated with a third party representing Aetna. He added that comparisons with some earlier rates are unfair because they represent fees when Hannallah was an in-network doctor.
The Aetna lawsuits, filed separately over the last eight months, allege the defendants violated New Jersey Board of Medical Examiners rules against excessive fees, and seek triple damages under state insurance-fraud laws against filing false or misleading claims.
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