maandag 5 maart 2012

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On Dec 7, 2011, Aetna filed a lawsuit against two PPO surgeons and one out-of-network (OON) hospital, in the District Court, Harris County, Texas. Aetna lawsuit seeks to recover damages and attorneys’ fees and for court temporary injunction to stop the OON hospital’s UCR billing and PPO surgeon’s referrals, alleging breach of contract, conspiracy to overcharge, tortious interference, and common law fraud, including “a bill for $99,750 for the removal of ear wax”. A new 2012 “UCR war” already unfolds in the court. offers private Webinars to examine this court case, its profound impacts on all OON providers, and explore compliant solutions and protections under ERISA and PPACA as well as OIG Guidance.

Aetna OON UCR Case info: AETNA HEALTH INC vs. SOFOLA, IFEOLUMIPO O (MD) (Case #: 2011-73949 / Court 152)

In 2012, most out-of-network (OON) doctors, surgical centers and hospitals will “make it or break it”, depending upon the outcome of this new Aetna lawsuit, as an emerging trend in managed litigations.

“While the alleged $99,750 ear wax UCR fee may or may not be an isolated inadvertent error, the payor’s new lawsuit to outlaw all OON UCR billing as fraud certainly represents a new 2012 trend and detrimental blow to all OON providers and 77% of insured Americans in private industry,” says Dr. Jin Zhou, president of, a national expert on PPACA and ERISA appeals and compliance.

“Failure to recognize the impact of the payor UCR legal actions under $99,750 ear wax anti-fraud strategies and to quickly act with compliant solutions, the OON market will most likely fail by the end of 2012,” warned Dr. Zhou.

According to the court documents, “Plaintiffs Aetna Health Inc. and Aetna Life Insurance Company (collectively, “Aetna”) bring this action under the laws of this state against Defendants Ifeolumipo O. Sofola, M.D. (“Dr. Sofola”), Navin Subramanian, M.D. (“Dr. Subramanian”), and Humble Surgical Hospital, LLC (“HSH LLC”), for breach of contract, unlawful and excessive fees, and to recover damages and reasonable attorneys’ fees for injuries Aetna suffered as a result of the Defendants’ scheme to steer patients to Humble Surgical Hospital (“HSH”), a “non-participating” surgical hospital owned or leased by HSH LLC in which Drs. Sofola and Subramanian through their membership in HSH LLC had a financialinterest. HSH in turn sought and received excessive fees from Aetna and its members, charging fees far higher than the reasonable charges for the same services in the relevant market.”

In particular, Aetna alleges self-referrals, cost sharing waiver fraud, non-disclosure of OON referral and UCR billing as deceptive practice to drive up the cost of health insurance:

“The self referral of an insured patient by a ‘participating’ physician to a ‘non-participating’ facility to gain direct and indirect financial benefit from the excessive fees charged by the ‘non-participating’ facility is a wrongful practice resulting in the unjust enrichment of both the referring physician and the facility,” according to the complaint.

“To encourage patients to use HSH rather than a ‘participating’ hospital, the HSH staff has on occasion assured patients that they will only owe the remaining portion of any ‘in-network’ deductible or will otherwise not be subject to higher out-of-pocket costs,” the complaint states.

“After admission, HSH submits excessive fee requests to Aetna, such as a bill for $99,750 for the removal of ear wax, that it would not be able to submit were it a ‘participating’ or ‘in-network’ hospital.”

“Even when the patient is reassured that HSH will not attempt to collect more from the patient than the out-of-pocket coinsurance, deductible or other patient-responsibility charges that the patient would incur were HSH an in-network hospital, both Aetna and the patient are deceived”.

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