Aetna’s Threats to Fire Doctors Who Referred Patients to Out-of-network is Legal?
Get ready to have your mind blown. After a 9 year battle the 2nd Appellate District’s ruled that:
Aetna’s threatening to fire doctors who referred patients to out-of-network facilities does not violate California’s unfair competition law, as the industry group advocating on its physicians’ behalf was not directly harmed by the insurer’s policy, an appellate court ruled on Wednesday.
Feel free to close your mouth now. Can you imagine having any less power on the job than doctors have now? They cannot even advocate for their patient’s care without the ‘legal’ threat of being fired.
For what it’s worth, sounds like the case was kicked over lack of standing. Sounds like the merits of the case never discussed in court.
Yeah, been a lot of that the past six months…
For what it’s worth, looks like the case was kicked over lack of standing. The issue of the insurance company forcing doctors to use their consultants was never considered.
I think the California Medical Asociation needs to work with a better law firm.
And the telemedicine fraud begins.
Recruit the patients, bribe the telemedicine doctors, order expensive and unnecessary testing.
https://healthcarefraudgroup.com/news/patient-recruiter-sentenced-in-2800000-u-s-dollars-telemedicine-conspiracy-against-the-medicare-program/
https://www.newsweek.com/florida-man-ivan-andre-scott-gets-10-years-role-33-million-genetic-testing-fraud-scheme-1583718
I would imagine there’s a beauty in using telemedicine doctors like this, multiple doctors, scattered all over the country, making it harder to pinpoint the fraud.
I have spent the better part of 20 years in Case Management and Utilization Review at a smaller hospital. We used agency hospitalists. They were never in network. For some of the managed plans, our hospital is not in network. Closest hospital is 40 miles away and also not in network. That leaves 90+ miles to a facility that might be in network. Some managed plans do not have out of network coverage. What are they to do when they are sick? We have one DME agency in our town and the next closest DME is 40 miles away. If the local DME is out of network and the one 40 miles away is in network but will not supply a walker because it’s not cost effective, what are the options to obtain DME? The same with Home Health. Every day there is a denial from Medicare Managed plans stating treatment could be done as an outpatient. The secondary review (that the hospital pays big bucks to use) says, “Just submit it as outpatient. You can’t get it overturned. The denials won’t stop until hospitals get together and sue those insurance companies.”. So even if the elderly patient came in with symptomatic hyponatremia ( Na 114, confused, weak and falling), and met ICU level of care per InterQual, we had to bill her 4 days stay as outpatient. And then, she had to pay out of pocket for skilled nursing placement because she was outpatient and didn’t meet the 3 day inpatient criteria. Patients think they are saving so much using a managed plan and it makes me ill. Many of the elderly in this area receive $1000/month Social Security and that is their entire income. They won’t qualify for Medicaid. They have to use a managed plan if they want to buy food and their medications. Not sure how they are paying utilities or any other bills. I quit working last fall, but the worry for these people nags me every day still.
Nancy, would you mind if I shared your comment (in full) in the Viva Barnes Law Community on Dave Rubin’s Locals.com? (https://vivabarneslaw.locals.com/)
With patience being billed astronomical amounts out of network and some physicians being financially irresponsible this is a difficult question. If you are a patient referred to a surgeon by your doctor and trusting it to be covered and later finding out you owe $50,000 out of network it’s a catastrophe. Furthermore the doctors are not being fired from their jobs but fired from this network. In this case I have to side with the insurance company as that is the right decision for patients, and if the doctors can’t understand that they should then not join that network.
We are currently receiving such threats from Cigna. I will be posting on this soon.
But where are the California Medical Association’s CEO Dustin Corcoran, and its lobbyist Janus Norman (attendees-of-honor at Gov. Gavin Newsome’s infamous “French Laundry” dinner)? Certainly the CMA will exert its considerable influence on the state house to achieve executive / legislative pressure to protect physicians?
Nah. I’m guessing Aetna will pick up the next dinner bill. Maybe they’ll invite some judges, too.