The California Medical Association and more than 60 individual physicians in the state are suing insurer Aetna for allegedly threatening to deny coverage for out-of-network health care services, the Los Angeles Times reports.
Plaintiffs in the lawsuit also include three county medical groups, four surgery centers and an unidentified patient.
The lawsuit was filed in Los Angeles County Superior Court (Terhune, Los Angeles Times, 7/4).
Lawsuit Details
The plaintiffs allege that Aetna routinely threatens to deny patients' coverage if they seek care from out-of-network physicians, even if their plan allows them to do so.
According to the lawsuit, Aetna also threatens to terminate member physicians' contracts if they refer patients to out-of-network health care providers (O'Neill, "KPCC News," KPCC, 7/3).
The lawsuit seeks an injunction against Aetna's practices. In addition, the plaintiffs seek reinstatement of physicians whose contracts they believe were unfairly terminated by Aetna.
Aetna's Response
Anjie Coplin -- spokesperson for Aetna -- said that physicians are referring patients to out-of-network facilities that they own without disclosing the potential conflict of interest (Los Angeles Times, 7/4).
In February, Aetna filed a lawsuit alleging that several California health care providers sent Aetna members to Bay Area Surgical Management and several ancillary facilities without disclosing that physicians had an ownership interest in the facility or were receiving payment for the referrals.
The insurer said the physicians' recent lawsuit is retaliation for the allegations.
Cynthia Michener -- spokesperson for Aetna -- said, "We have sued some of these same doctors and surgery centers named in the suit for their egregious billing practices." She added, "This is a countersuit disguised as a class-action lawsuit" (Clarke, Reuters/San Jose Mercury News, 7/3).
Implications
Experts say that similar disputes might develop as more provisions of the federal health reform law are enacted.
Shana Alex Lavarreda -- director of health insurance studies at the UCLA Center for Health Policy Research -- said, "These contract dispute tensions will intensify in the next few years as the new Affordable Care Act regulations force insurers to keep a tighter rein on their networks."
Lavarreda added, "Consumers could be affected by increased network disruptions" (Los Angeles Times, 7/4).