Are prices out of control in health care? Check out this true story shared with me by Phil James, Director of Ultrasound and Nuclear Medicine at GVMH.
Aetna is suing six New Jersey doctors over such bills as $59,490 for a cardiac ultrasound.
The real issue is control (or lack of it) over prices charged by out-of-network doctors. Aetna describes fees charged to it by the six doctors “unconscionable.”
David Lansky, president of the Pacific Business Group on Health, concurs. “If these charges are accurate, consumers and purchasers should be outraged,” he told Bloomberg News. The organization is a coalition of health-insurance buyers that includes such corporate behemoths as Chevron, Disney, and General Electric.
Not so fast, say the doctors—or at least their lawyers. Benyamin Hannallah, MD, a cardiologist with privileges at Jersey City Medical Center and other hospitals, is one of the doctors being sued. He’s the one who submitted an out-of-network bill of $59,490 for a heart ultrasound in April 2010 (and was paid $47,592), according to the suit. An Aetna spokeswoman said Aetna reimburses in-network physicians $74 for the procedure at Jersey City hospitals.
Dr. Hannallah’s lawyer, Robert Conroy, responded thus to the Jersey Journal newspaper in Jersey City:
Aetna is either the stupidest company in the world or the most negligent in the world.
Doesn’t sound as if he’s in a mood to settle.
Gordon said the fees paid to Dr. Hannallah were negotiated by a third party and agreed to by Aetna. He also said that some of the fees were obvious errors in billing and that some of Dr. Hannallah’s patients or their employers paid higher insurance premiums for the right to use out-of-network doctors.
And Gordon said Aetna was simply trying to inflate already-healthy profits. “How much did Aetna pay its CEO last year?” he asked. “How many lives did he save while feathering his nests?”
New Jersey regulators seem to be on the doctors’ side. In 2007, Aetna tried to impose caps on some out-of-network payments. The New Jersey Department of Banking and Insurance sided with the doctors, fined the company $2.5 million, and ordered it to pay out-of-network practitioners enough so that patients would owe nothing more than copays.
And in 2009, the New York attorney general accused Aetna and three other insurance companies of underpaying out-of-network physicians. The four insurers did not admit wrongdoing but paid a total of $90 million in settlements.
The doctors may have regulators and feisty lawyers on their side. But the sort of fees alleged in the lawsuits—including $54,600 for a heart catheterization and $5,500 for an electrocardiogram—are not going to play well with the public during the ongoing arguments about health-care reform.