Aetna Sues Doctors and Hospital for Outrageous Charges

Over $99,000 for ear wax removal? That’s one of the many charges that Aetna claims it received from two doctors who were referring insured patients to their out-of-network hospital.

According to the Courthouse News Service, Aetna Health and Aetna Life Insurance sued Drs. Ifeolumipo Sofola and Navin Subramanian, and Humble Surgical Hospital (HSH), in Harris County Court.

While Sofola specializes in ear, nose and throat issues, Subramanian is an orthopedic surgeon. The complaint notes that both men practice at several places in the Houston area.

Aetna states that it “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.”

Aetna also says that the doctors, who along with other doctors have an ownership interest in HSH, are running a scam called self-referral.

“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 notes that once the doctors refer their insured patients to HSH, the hospital staff takes it from there.

The complaint notes that Aetna stated, “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.”

“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 also says such deceptive practices by doctors and hospitals are helping 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 is seeking “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,” along with a permanent injunction that will stop the defendants from trying to hold its plan members responsible for any additional payments for services.

Aetna has sued Sofola and Subramanian for breach of contract, and Humble Surgical Hospital for tortious interference, along with all the defendants for conspiracy, fraud and unjust enrichment