Last updated on April 17, 2014 at 9:59 EDT

Classic David Vs Goliath Case, Aetna Bullies Surgical Group, Threatens Patients’ Choice Lawsuit, According to BASM

February 24, 2012

SARATOGA, Calif., Feb. 24, 2012 /PRNewswire/ — Insurance giant Aetna Inc. is using aggressive litigation tactics to strong-arm family-run Bay Area Surgical Management (BASM) into making patients of their affiliated surgery centers use only Aetna-affiliated facilities. With legal action and threats, the billion-dollar insurance company is trying to get away with not paying providers fairly and taking away patients’ right to use a provider of their choice.

“This is a calculated move by Aetna to steer patients to contracted facilities,” said attorney Daron Tooch, Partner at Hooper Lundy & Bookman, P.C., who is representing BASM in the case. By attacking out-of-network providers who are simply trying to deliver the best care, “patients’ right to choose is being threatened,” he added.

In what has developed as a classic David versus Goliath case, Aetna is accusing BASM of purposefully sending patients to out-of-network providers, waiving co-pay responsibilities, and then overcharging the insurer for the services provided, according to the suit, filed on Feb. 2 in Santa Clara Country Superior Court.

According to Tooch, Aetna’s claims have no legal basis. “The complaint is full of misstatements of fact and law,” said Tooch. “We intend to seek dismissal at the earliest opportunity. There is nothing in the law that precludes PPO patients from going out of network for services, and Aetna’s own benefit plans allow it.”

Aetna seems to think otherwise. This month, the insurance company terminated its contract with one of BASM’s centers, the Sports Orthopedic & Rehabilitation Medicine Associates (SOAR), for not referring members to participating facilities and providers.

Aetna Pays Unfairly
The real story is that Aetna wants to intimidate surgery centers into signing provider contracts with unfairly low rates, said Bobby Sarnevesht, a representative for the company. “Aetna thinks they can pay what they want because they hold all of the strings,” he said.

Because of this, BASM filed two suits against the insurer to collect medical bills that were never paid. Those suits have not yet gone to trial. “The timing is not coincidental,” Sarnevesht said. “It seems that Aetna is now trying to get our attention.”

BASM, which manages 7 surgery clinics, imaging centers and medical laboratories in the San Francisco Bay Area, has more than 100 award-winning physician-partners and a highly skilled team of nurses and healthcare professionals. Despite this, the clinics being sued still charge only 60% to 70% of what larger, more well-known institutions charge, according to Sarnevesht.

“There is no standardization in Aetna’s contracting process – it is whoever can negotiate best,” Sarnevesht said. “These surgery centers are often paid only a fraction of what Aetna pays some larger providers. Aetna needs to treat everybody fairly.”

In addition, Aetna pays BASM’s providers sporadically. “Sometimes, they don’t pay us at all,” Sarnevesht said. “There is no rationale behind Aetna’s payment method.” For example, the insurer once denied payment for a cancer colonoscopy, claiming the procedure was cosmetic.

BASM is not alone in its struggle against Aetna. The mammoth insurance company also has accused out-of-network providers of overcharging in at least six other lawsuits. According to Sarnevesht, “the result of Aetna’s strategy of suing out-of-network providers would not bode well for patients, who would suffer from less choice while continuing to see a rise in premiums despite insurance companies reaping billions of dollars in profits.”

“What is your life worth to Aetna?” Sarnevesht asked. “That depends on who is doing your negotiating.”

For media interviews contact, Linda Zanides, Zanides Communications, 415.456.8171


Source: PR Newswire