New Jersey artistic map

New Jersey artistic mapThe Aetna lawsuit in New Jersey seemed so puzzling that we continued reporting on it, following links.

Why would Aetna pay such ridiculous rates, including a payment of $56,980 for a bedside consultation and “$59,490 for an ultrasound that typically costs $74”? That just seems absurd; we have a hard time getting $23.40 out of the insurance company, let alone $59,000.

The back story of the case includes this announcement from the state of New Jersey about a July 2007 administrative order apparently laying the groundwork for the misbehavior at the heart of the case.

“TRENTON – On Monday the Department of Banking and Insurance (DOBI) filed an administrative order levying $9,475,000 in fines against Aetna Health Inc. for refusing to appropriately cover certain services provided by out-of-network health care providers – including emergency treatment – in violation of New Jersey rules and regulations.

“In June, DOBI received numerous complaints after Aetna issued a letter to health care providers stating that the company had determined what was ‘fair payment’ for services rendered by non-participating physicians and health care facilities and that ‘additional reimbursement would not be considered.’ This included services by non-participating providers that were required under New Jersey law, such as emergency care, services provided by non-participating providers during an admission to a network hospital, and services rendered as the result of a referral or authorization by Aetna.”

In other words, Aetna apparently made a judgment call about what a non-network provider should get for a procedure, the providers complained, and the Jersey regulators sided with the providers. That apparently meant that Aetna should pay whatever the providers billed, meaning that $74 procedure actually is reimbursed for non-network providers at $59,490.

Whether this is true of all non-network providers is a question one wants to ask. Aetna is suing six doctors; did others do similar things, even if perhaps less egregious? We’re wondering.

In any case, this seems to be a good argument for bringing transparency to the health-care marketplace.

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...