The California Medical Association is headlining a suit with several other medical societies and provider plaintiffs that sued Aetna in California state court on July 3, alleging that Aetna is retaliating against patients, physicians and out-of-network facilities alike for using out-of-network benefits. The complaint specifically involves Aetna's preferred provider organization and point-of-service policies which are stated to allow beneficiaries to seek care from out-of-network providers. According to the complaint, the physician contracts "do not require the physicians to refer all Aetna patients . . . only to in-network providers." The plaintiffs, including one anonymous Aetna beneficiary, claim that Aetna has improperly threatened beneficiaries who have attempted to use these out-of-network benefits. The complaint also alleges that Aetna has retaliated against contracted physicians who have referred their patients to out-of-network ambulatory surgery centers by threatening to, and in some circumstances, actually reducing reimbursement rates or terminating the physicians from the network. At least one physician who was sent a termination letter had received preapproval for the out-of-network services at issue.
The plaintiffs allege that Aetna's behavior is in contradiction to California Insurance Code provisions and other statutory provisions that prohibit insurers and employers from interfering with the medical judgment of contracted physicians. The plaintiffs' causes of action include false advertising, unfair business practices and breach of contract, among others. They also allege that Aetna's actions constitute a breach of a 2003 class action settlement involving Aetna and several other insurers and physicians prohibiting "gag clauses" that restrict a physician's open communication with an insured regarding his healthcare.
This suit follows on the heels of recent lawsuits filed by Aetna against some of the plaintiff physicians and other California and Texas physicians and out-of-network facilities alleging fraud and unjust enrichment, in addition to other wrongdoing attributable to so-called "out-of-network strategies." You can read our previous coverage of the Texas case. Providers are signaling a desire to fight fire with fire, and we will continue to monitor the contentious relationships between networks and providers.