Follow up on Fight Between California Doctors and Aetna

Our San Francisco insurance attorneys have been following a big California insurance story as it continues to unfold. In July, this blog discussed a lawsuit filed by groups of California doctors against Aetna insurance for denying patients access to out-of-network doctors, even when the patient purchased a policy that allows for this out-of-network option (see post here).

This week, one of the doctor’s groups involved in the lawsuit, the California Medical Association, which is the largest such group in the state with 35,000 members, accused Aetna, the country’s third largest insurance provider, of refusing to negotiate with member doctors and kicking member doctors out of the network in retaliation for this lawsuit. Dr. David Aizuss, an ophthalmologist in Los Angeles and a plaintiff in the lawsuit, said Aetna notified him earlier this month that his contract would terminate in November. He claims it is retribution for participating in the lawsuit. The result, says the California Medical Association, is that patients are being further limited in their access to their regular doctors. Dr. Aizuss told the Los Angeles Times, “They are impacting the doctor-patient relationship for thousands of people.” nurse.jpg

Aetna responded to this latest argument from the California Medical Association by saying it is fighting on behalf of patients. But Aetna may not be so happy with the outcome, as the director of health insurance studies at the UCLA Center for Health Policy Research says many consumers choose their insurance specifically to be able to stay with their doctor, and these actions will probably lose Aetna customers. But Aetna has been firm in claiming that doctors are overbilling insured patients for procedures outside of the network, and filed its own lawsuit to this effect in February. Aetna claims that these doctors are unscrupulously steering patients to out-of-network facilities that they own or partly own for their own profit, without informing patients of this conflict of interest as required by federal law. The company claims these inflated bills jack up prices for patients and increase premiums for all consumers.

Divisions and disputes between doctors and insurance companies are nothing new. But this lawsuit comes at an important time in health insurance reform as the federal healthcare law, called “Obamacare”, moves forward (see a post on this issue here) insurers will face more scrutiny of their hospital and doctor networks from state insurance exchanges. These exchanges will become even more important in 2014 when millions of consumers will purchase health insurance through them.

Regardless, as both of these powerful and wealthy groups–doctors and insurers–fight it out in the courts, it is the policyholders and patients who suffer the most. Patients are constantly caught in the crosshairs of these arguments over profits and money, with both sides doing what they can to make the most of it. If you or someone in your family is having trouble with health insurance issues, it can be devastating. Legal advice about your individual case and how the law can be used to help you can be invaluable, so contact an experienced California insurance lawyer in your area.

See Our Related Blog Posts:

Doctors’ Group Sues Aetna for Coverage Denials

“Death Spiral:” Blue Shield Pushes Customers into Overpriced, Bad Coverage

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