LOS ANGELES (CN) – In a class action, a doctor claims that Aetna kicks physicians out of its plans if they refer patients to out-of-network providers for necessary medical treatment.
Plaintiff Dr. Marc Kerner claims that Aetna “coerce(s)” doctors to use only in-network providers, even if in his “medical judgment” his patients need an out-of-network doctor to get proper care.
He sued Aetna Health Plans of California and affiliates for the class of health-care providers, in Superior Court.
Health insurers typically offer coverage for treatment from their network providers at a discount, while out-of-network providers charge patients their usual rate.
Kerner claims that Aetna threatened him with termination for making the referrals, then kicked him off its provider network altogether.
He claims that other providers have received similar treatment for making out-of-network referrals.
“Defendants engage in the aforementioned conduct because their profit margins are higher for care provided in network and defendants hope to coerce their providers to refer patients in network rather than based on what care would be best for the patient,” the complaint states. “In that regard, when such approval was sought for out-of-network treatment, defendants would send a letter to the member advising them of such a request and that increased charges to the member would result.”
Kerner claims that Aetna “directly affects the health and well-being of the public at large” by putting profits before the health-care needs of its customers.
“Rather, defendants are engaging in a scheme whereby they seek to limit use of out-of-network providers by terminating those providers who refer patients out-of-network without regard to the sound medical judgment that was used to make such a referral,” the complaint states.
Kerner seeks an injunction, restitution and damages for unfair competition and unreasonable restraint of commerce in violation of California’s Cartwright Act.
He is represented by Raymond Boucher with Kiesel Boucher Larson of Beverly Hills.