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California Doctors Sue Aetna For Routinely Denying Out of Network Patient Access–Grading on the Curve Algorithms Versus In

Posted Jul 04 2012 3:42pm

This lawsuit should be interesting indeed as I’m sure there’s a little of both sides in here, relative to Aetna claiming over charging at surgical centers and then again there are those situations to where the Out of Network charges were in line but didn’t meet the Aetna Algorithms for quality and cost control.  I think the over billing by facilities by facilities owned by doctors exists but in reality is probably a small portion of this entire case. Like everything there are those out there that find loopholes and milk it.  Aetna is probably correct on a case by case basis on some of the billing that takes place with way beyond normal customary fees but again you can’t use this as a “whole” perception when you look at all of it.  I read one example here about a kidney stone fragmentation questioned to where Aetna claims $7,612 should have been the appropriate charge and they were billed $73,536 and there’s certainly enough in between those two numbers to question.

It’s also again a case by case situation as we don’t have more information than the numbers quoted so what else was in the bill I think anyone would ask, were there complications, etc.  Obviously Aetna has some pressure here with first quarter results and answering to shareholders.

The link above is actually pretty interesting as there are a couple other links that describe some strange events. This one in particular is kind of odd…with patients being told their doctor is no longer in network, but yet was a mistake?  Yup we come right back around to accounting and business intelligence algorithms here setting the stage. 


I think they are having a hard time with some of this and granted there are some way out of whack charges that they should contest but when running analytics in some areas on percentage points, I think thisimage is where we get down to some tit for tat issues.  Doctors are graded in the Aetna system just like all other do and an MD maybe staying right within the suggested areas until it happens, one very sick patient who needs care outside of what the in network specialists can provide.  That patient gets referred to a “specialist’s specialist” and none of those folks are on the “approved in network” lists anywhere for the most part.  The patient goes and receives treatment and the big bill comes back and analytically even though it was approved, the “out of network” algorithm catches it, just looking at the amount of the bill. 

In yet another area an analyst might see this and “flag” the doctor for going outside of the normal and customary charges without perhaps looking at the entire case, numbers “say”.  So you do have this situation that arises and one sick patient skews the numbers the insurer states he/she should stay within.

I understand trying to keep costs in control and it’s not easy, but it requires skills that go beyond “grading on a curve” if you will and this just goes to further explain the needs for each case to be investigated on it’s own.  This is a throw back to the HMOs when they first started here in California years ago.
In Texas several doctors were removed from contract by Aetna and again it may have caught some over billing but how many were caught in the “one sick patient” scenario that created the situation for them to fall out of favor relative to cost control?  Furthermore if the referral was initially approved and debated later, do we go back and look at what substantiated the referral in the first place? 
 


One other item worth a mention too is that insurers are branching into other types of businesses as well, like Health IT with purchasing subsidiary companies.  Here’s an example below of one of Aetna’s companies below that provides services to connect electronic records. 


In August of this year  folks in Colorado will no longerimage be able to purchase Individual Health insurance policies, so I am guessing they ran out of ideas and algorithms to keep this area profitable, but they will still continue to work with employer provided insurance plans. 

With the complex medical billing system we have today this is probably not something that will go away any time soon as on the other side there are consultants who help the folks submitting claims to maximize their income so we have the battle of the algorithms for profit and cost duking it out once again.  One doctor in New Jersey was so upset that he made a video about it and again I am assuming he might be one of those caught up in the “grading on the curve algorithm”, but again this shows how each case should be treated as it’s own to get to the bottom of why the doctor slipped out of grace with the insurer.  BD 




(Reuters) - Thousands of doctors in California are suing the health insurance company Aetna Inc claiming the company routinely denies patients access to out-of-network doctors even when the patient has purchased a policy giving them the right to choose providers.

The lawsuit, filed in the Los Angeles County Superior Court, accuses Aetna of threatening patients with denial of coverage if their members visit doctors outside the Aetna network of providers, and of threatening doctors with having their Aetna contracts terminated if they refer patients outside the network.

http://in.reuters.com/article/2012/07/03/us-aetna-lawsuit-idINBRE86214F20120703?feedType=RSS&feedName=health&utm_source=dlvr.it&utm_medium=twitter&dlvrit=309303


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