ultrasound on stomach

Aetna is unhappy: it received high bills from providers and paid them, and now it’s suing.

Aetna Inc. (AET) is suing six New Jersey doctors over medical bills it calls ‘unconscionable,’ including $56,980 for a bedside consultation and $59,490 for an ultrasound that typically costs $74,” Peter Waldman wrote on Bloomberg News on March 24.

“The lawsuits could help determine what pricing limits insurers can impose on ‘out-of-network’ physicians who don’t have contracts with health plans that spell out how much a service or procedure can cost.

“One defendant billed $30,000 for a Caesarean birth, and another raised his fee for seeing a critically ill patient in a hospital to $9,000 in 2008 from $500 the year before, the insurer alleges in the suits. The Caesarean price was more than 10 times the in-network amount Aetna quotes on its website.”

The problem, from my perspective, is that Aetna paid the fees first, and then sued. It seems certain to me that Aetna’s customers have the same difficulties getting their bills paid and their problems addressed that I do with my insurance company, yet these outsize claims were paid in full, and fast.

The story, based on suits filed in Camden, N.J., contains enough details to make you weep.

“In April 2010, Aetna said, [a cardiologist named Benyamin] Hannallah asked for $54,600 for a heart catheterization, up from $5,500 for the same procedure in 2007. When the insurer gave him $2,000 — a sum it deemed ‘usual and customary’ for the procedure — Hannallah complained, and Aetna paid in full to prevent him from billing the patient for the remainder …

“The amount Hannallah requested for heart ultrasounds quadrupled between 2009 and 2010, and his price for cardiac- stress tests rose more than tenfold to $15,850 between 2008 and 2010, Aetna’s suit claims. For an electrocardiogram, Aetna said it paid him $5,500 in 2010, up from $800 in 2008. The in-network fee listed on Aetna’s website for EKGs in Jersey City is $23.

“Aetna said it paid Hannallah a total of $3.2 million in 2008 and 2009, up from $529,503 in the prior two-year period.”

We’re going to get the court papers.

Oh, and Aetna explains why it paid up and then sued:

“Aetna reimbursed the defendants $8.3 million in 2009, up from $4.9 million in 2008, spokeswoman Cynthia Michener said, sometimes paying the full amount demanded and sometimes not. The insurer paid some of the large charges because of state regulations mandating timely payments and to prevent doctors from sending patients big bills, Michener said.”

Jeanne Pinder

Jeanne Pinder  is the founder and CEO of ClearHealthCosts. She worked at The New York Times for almost 25 years as a reporter, editor and human resources executive, then volunteered for a buyout and founded...