Friday, March 25, 2011
BY MARY JO LAYTON AND LINDY WASHBURN
One of the nation's largest insurers has sued six North Jersey physicians over bills it considers "unlawful and excessive," including $56,980 for a 25-minute bedside consultation.
In one case, Aetna Inc. claims it paid a Ridgewood neurosurgery practice $3.9 million more than it was entitled to receive. It also alleges the practice billed a patient $116,000, even after the insurer had provided payment in full.
In another case, Aetna claims a cardiologist at Hackensack University Medical Center increased his charges more than sixfold for catheterizations, from $3,000 to $18,720. The fees drove his income from Aetna up from $155,310 in 2006 to $2.5 million in 2008, according to the lawsuit obtained by The Record on Thursday.
The charges were incurred in out-of-network care, an area of growing concern among insurers and some state lawmakers eager to rein in the unregulated fees that drive up treatment costs and overall health care expenses.
"That's just one payer," said Ward Sanders, president of the New Jersey Association of Health Plans. "Extrapolate that out, and you've got to believe these doctors were making extraordinary sums," he said.
"I can certainly say that what Aetna has experienced, other payers have experienced," Sanders said.
Not only are insurers footing the bill, they're passing millions of dollars in excess charges on to those who buy insurance. High out-of-network charges "are factored into the cost of coverage that must be paid by individuals and businesses who are already saying that they can no longer afford the cost of health care," said Thomas Vincz, a spokesman for Horizon Blue Cross Blue Shield of New Jersey, the state's largest insurer.
Aetna alleges that the physicians violated New Jersey Board of Medical Examiners rules against excessive fees. The lawsuits, filed separately in Superior Court in Camden County over the last eight months, seek triple damages under state insurance fraud laws.
The six physicians were reimbursed $8.3 million in 2009, up from $4.9 million in 2008, Aetna spokeswoman Cynthia Michener said.
"You can't charge $56,000 for a $74 ultrasound procedure," she said, referring to a Jersey City cardiologist's bill.
'Captive in hospital'
The cases involve hospital care in which patients were referred to in-network hospitals but received care from out-of-network physicians who have no contracts and set their own charges, she said. Patients weren't informed of the physician's status and were never told of the fees, the lawsuits state.
"The members are captive in a hospital," she said. "It's the uninvited guest in your hospital room."
Dr. Waleed Abdelghani, an obstetrician at Hackensack University Medical Center, was a member of Aetna's network, according to one lawsuit that alleges he tried "to circumvent the terms of his participating provider agreement by submitting claims as a non-participating provider."
He billed Aetna for $30,000 for a cesarean delivery, up from his previously agreed amount of $3,000, and charged $15,000 for a vaginal delivery, compared with $3,200, according to the suit. As a result, his payments from Aetna rose from $137,000 in 2008 to $2.7 million for the first six months of 2010.
Abdelghani's lawyer, Charles Gormally of Roseland, did not return phone calls Thursday.
Deepak Srinivasan, a cardiologist at Hackensack University Medical Center, increased his fee from $1,400 to $16,380 for the first 30 to 74 minutes of services for critically ill patients, a lawsuit states.
Srinivasan declined to comment, but his attorney called Aetna's suit "a gross abuse of the judicial system."
"It's a naked attempt to extort millions of dollars from a practitioner with an impeccable patient care record," said George G. Frino. A counterclaim has been filed, Frino said.
One of the defendants, Dr. Magdy Wahba, a staff physician at St. Joseph's Regional Medical Center in Paterson, billed Aetna $9,000 for a bedside consultation lasting 30 to 74 minutes with a critically ill patient, the lawsuit said. Aetna's suit against him alleges he was overpaid by more than $4.1 million between Jan. 1, 2009, and March 31, 2010. Wahba threatened to sue his patients if Aetna did not pay his charges in full, the lawsuit said.
The six-count complaint, filed last July, said Wahba's charges were "excessive, manifestly unconscionable and overreaching."
Another lawsuit details the steps it alleges were taken by Neurosurgical Associates of New Jersey in Ridgewood to increase its payments. One partner, Dr. David Estin, was a participating provider, the lawsuit says, but he used two partners in the practice who were not in the Aetna network as assisting surgeons. Those doctors — Jonathan Lustgarten and Ty James Olson — then billed patients at higher out-of-network rates.
The patients were not informed that the assistant surgeons' fees would be billed at the higher rate and, in at least one case.