Aetna sues in New Jersey, Pt. 2

The 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.