Hospital group sues Aetna for allegedly denying out-of-network access

Two California hospital groups and thousands of doctors are suing Aetna for allegedly blocking its members from accessing out-of-network providers.

The California Medical Association (CMA), the Los Angeles County Medical Association (LACMA) and two doctor coalitions have sued Aetna in state court, claiming the insurer has threatened to deny patients' coverage for visiting out-of-network doctors and to terminate doctors' contracts if they refer patients outside the network, Reuters reported.

The medical groups--along with the Santa Clara County Medical Association, the Ventura County Medical Association, 60 physicians and four surgery centers--also accuse Aetna of engaging in false advertising, breach of contract, unfair business practices, as well as intentional and negligent interference with providers.

"This lawsuit is about defending patient rights to quality care, which Aetna is ignoring," CMA CEO Dustin Corcoran said in a statement. "It's about protecting the patient-physician relationship, which Aetna is seeking to destroy in its relentless campaign to cut costs and boost profits. It's about making Aetna live up to its promises. It's about saying 'enough is enough.'"

Aetna, however, said the lawsuit is a retaliatory effort in response to its own suit against the Bay Area Surgical Management California for alleged illegal overbilling practices. "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," Aetna spokeswoman Cynthia Michener told Reuters. "This is a countersuit disguised as a class action lawsuit."

The problem, Aetna said, is that doctors have been referring their patients to out-of-network facilities that they own, without disclosing the potential conflict of interest and then charging inflated prices, reported the Los Angeles Times.

To learn more:
- read the Reuters article
- see the Los Angeles Times article
- check out the LACMA statement