HOUSTON (CN) – Aetna claims two doctors self-referred insured patients to their out-of-network hospital so it could charge dizzying fees, including “a bill for $99,750 for the removal of ear wax.”
Aetna Health and Aetna Life Insurance sued Drs. Ifeolumipo Sofola and Navin Subramanian, and Humble Surgical Hospital, in Harris County Court.
Sofola specializes in ear, nose and throat issues, and Subramanian is an orthopedic surgeon. Both men practice at several places in the Houston area, according to the complaint.
Aetna says it had “entered into separate Specialist Physician Agreements with Dr. Sofola and Dr. Subramanian governing the terms of their participation in Aetna’s nationwide network of physicians, hospitals and other health care professionals.”
The doctors, who along with other doctors have an ownership interest in Humble Surgical Hospital, are running a scam called self-referral, Aetna says.
“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.
“Indeed, some physician investors in HSH have publicly boasted about high payments they receive as a result of having an ‘out-of-network’ strategy.”
Aetna says once the doctors refer their insured patients to Humble Surgical Hospital, the hospital staff takes it from there.
“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.”
Aetna says such deceptive practices by doctors and hospitals work to drive up the cost of health insurance.
“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.
“Aetna is deceived, because by submitting an inflated and unreasonable bill for payment without disclosing its waiver agreement with the patient, HSH misrepresents the charge the patient actually agreed to pay.
“The patient is also deceived, because HSH’s intent to overbill Aetna is not disclosed, and injured, because such egregious billing practices ultimately result in the patient paying more for health care services as the cost of health care insurance rises in response to the excessive fees charged by providers who engage in this type of ‘out-of-network’ strategy,” Aetna says.
Aetna seeks “to recover damages and disgorgement by defendants of all amounts in excess of the usual, customary and reasonable billed charges for the covered services rendered to Aetna beneficiaries,” and a permanent injunction to stop defendants from trying to hold its plan members responsible for any additional payments for services previously rendered.
Aetna sued Sofola and Subramanian for breach of contract, and Humble Surgical Hospital for tortious interference, and all the defendants for conspiracy, fraud and unjust enrichment.
Aetna is represented by John Shely with Andrews Kurth in Houston.