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Aetna sues doctors over bills it calls 'excessive'
Friday, March 25, 2011
Last updated: Friday March 25, 2011, 7:36 AM
BY MARY JO LAYTON AND LINDY WASHBURN
The Record
STAFF WRITERS
One of the nation's largest insurers has sued six North Jersey physicians over bills it considers "unlawful and excessive," including $56,980 for a 25-minute bedside consultation.
In one case, Aetna Inc. claims it paid a Ridgewood neurosurgery practice $3.9 million more than it was entitled to receive. It also alleges the practice billed a patient $116,000, even after the insurer had provided payment in full.
In another case, Aetna 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, according to the lawsuit obtained by The Record on Thursday.
The charges were incurred in out-of-network care, an area of growing concern among insurers and some state lawmakers eager to rein in the unregulated fees that drive up treatment costs and overall health care expenses.
"That's just one payer," said Ward Sanders, president of the New Jersey Association of Health Plans. "Extrapolate that out, and you've got to believe these doctors were making extraordinary sums," he said.
"I can certainly say that what Aetna has experienced, other payers have experienced," Sanders said.
Not only are insurers footing the bill, they're passing millions of dollars in excess charges on to those who buy insurance. High out-of-network charges "are factored into the cost of coverage that must be paid by individuals and businesses who are already saying that they can no longer afford the cost of health care," said Thomas Vincz, a spokesman for Horizon Blue Cross Blue Shield of New Jersey, the state's largest insurer.
Aetna alleges that the physicians violated New Jersey Board of Medical Examiners rules against excessive fees. The lawsuits, filed separately in Superior Court in Camden County over the last eight months, seek triple damages under state insurance-fraud laws.
The six physicians were reimbursed $8.3 million in 2009, up from $4.9 million in 2008, Aetna spokeswoman Cynthia Michener said.
"You can't charge $56,000 for a $74 ultrasound procedure," she said, referring to a Jersey City cardiologist's bill.
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