Doctors’ lawsuit paints Aetna as a PPO bully [Ventura County Star, Calif.]

July 14--One of the nation's largest insurance companies bullies clients who use out-of-network doctors even when they pay for that privilege, according to allegations in a statewide lawsuit involving doctors in Ventura County.

The lawsuit filed in Los Angeles County Superior Court claims Aetna terminates or threatens to end its contract with doctors who refer patients to specialists or surgery centers not under contract with the insurance company, meaning the insurer, and possibly the patient, may have to pay more.

The suit alleges Aetna also sends threatening letters to patients and sometimes refuses to pay for out-of-network care even though the flexibility to choose doctors comes with the higher cost of Preferred Provider Organization policies, known as PPOs.

"Aetna tries to intimidate the patient and the doctor," said Dr. Vipin Tandon, a Simi Valley general surgeon and one of dozens of named plaintiffs in litigation filed on behalf of thousands of doctors across California. Tandon said he was threatened with having his Aetna contract terminated and his patients were sent letters advising them not to use out-of-network facilities.

"My patients are being threatened," he said. "They are paying a higher premium and here is an insurance company making billions of dollars and when the time comes to use that service, the patients are being intimidated."

An Aetna spokeswoman said no threats have been made against patients.

The lawsuit was filed this month by the Los Angeles County Medical Association; the California Medical Association, which represents 35,000 doctors; and other doctor groups, including the Ventura County Medical Association. Tandon, Ventura and Santa Barbara glaucoma specialist Bryant Lum, the Simi Surgery Center and Ventura Ophthalmology Medical Group are all listed as plaintiffs.

Other participants include Bay Area Surgical Management in Northern California and affiliated surgery centers. Those groups are being sued by Aetna for allegedly using out-of-network referrals to rack up profits. Aetna alleges the doctors refer patients to centers they own without disclosing that financial involvement.

Because they're part owners in the centers, the doctors get a cut of the profits caused by the referrals, Aetna alleges. They convince patients to go to the centers by waiving out-of-pocket charges, the lawsuit claims.

A spokesman for Bay Area Surgical Management said all the claims are baseless.

The new lawsuit by the state and local medical associations is a way of retaliating against Aetna for its charges, said Anjanette Coplin, a spokeswoman for the Connecticut-based insurance company.

"Aetna's actions protect our members from the small number of doctors who are putting profits ahead of patient care," she said. "Doctors who entice patients to have procedures performed at out-of-network facilities that they own without the patient's knowledge are putting profits over their patients."

Tandon and Lum, who are not part of the Bay Area lawsuit, both contend Aetna is trying to limit its costs by keeping patients from using out-of-network providers.

Keith Wintermute, administrator for Lum's medical practice, said Aetna terminated the doctor's contract last year because he referred patients to an out-of-network surgery center. Patients either had to find a new doctor or pay out of pocket to see Lum.

"If you as a physician refer anyone to an out-of-network provider, they're saying you're violating your contract," he said.

Aetna's Coplin said Lum was sending patients to Pacific Surgery Center of Ventura, in which he's a shareholder. She said Aetna tried repeatedly to contract with the center but was rebuffed.

"We're trying to keep health care costs low," she said, contending that sending patients to doctors contracted with Aetna helps reduce medical bills and maximize care that is covered for patients.

"We're not the ones who are putting profits before patient care," she said, referring in general to doctors who bypass contracted surgery centers to bill with out-of-network centers that may be paid more. "It seems to me that they're profiting from referrals to out-of-network facilities, particularly if they have an ownership stake."

Wintermute said the insurer is trying to force surgery centers into contracting with it. He said Lum refers patients to Pacific Surgery Center because he has more control over their care there.

"Doctors are not gaming the system," he said. "That is a grossly simplistic and illusionary argument. That's not the case at all."

He said a core issue is that Aetna is charging members more money for the right to choose their doctors and then is working to block that option.

Cipriano Munguia, 31, of Simi Valley underwent a surgery on his right elbow two years ago at the Simi Surgery Center. His Aetna PPO plan still hasn't paid any part of the $13,000 bill, he said.

Although Munguia has been covered for other procedures at the center, he thinks the refusal comes because the facility is out-of-network. Aetna sent him a letter saying he should have picked a contracted site.

"I'm paying for the benefits to choose where I want to go," said Munguia, who is a surgical tech at the center. "When you use the benefits you're paying for, they're on you."

Coplin said Aetna hasn't threatened patients, acknowledging a PPO policy allows them to go out of network. When doctors bypass facilities under contract with Aetna and send patients to out-of-network sites, the physicians are warned several times. If the warnings are ignored, their contracts may be ended, she said.

"The question should be: If there are in-network facilities, why would a doctor push patients and our members to out-of-network facilities?" she said, directing the question to doctors in the lawsuit.

Tandon said he has been warned for sending patients to the Simi Surgery Center, in which he is a shareholder along with 13 other doctors. He said he sends patients there because the center has equipment like a brain lab for sinus surgery and equipment used for procedures involving varicose veins.

"They're absolutely wrong if they think patients will be referred for money," he said, citing insurance company rate hikes and profits. "Who's talking about greed?"

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