Aetna’s Lawsuits: Earthquakes of the U.S. Out-of-Network Healthcare Landscape

Share Article offers new webinars to examine the recently reported Aetna’s high profile lawsuits against out-of-network hospitals, surgical centers and doctors across the nation, allegedly for not collecting deductible and co-insurance in CA and TX and over collecting (balance billing) in NY and NJ.

Obviously, if not collecting or waving co-insurance in CA and TX, but collecting or balance billing for unpaid claims in NY and NJ, the OON providers may get sued both ways. offers new executive Webinars to examine the recent news reports of Aetna’s high profile lawsuits against many out-of-network hospitals, surgical centers and doctors across the nation, allegedly for not collecting deductible and co-insurance in CA and TX, and over collecting (balance billing) from the patients in NY and NJ. The Webinars will alert the healthcare executives of this breakthrough Aetna litigation epidemic and propose for practical strategies and solutions to avoid possible litigations through proactive and compliant practices.

“We are certainly NOT in a position to judge the merits of these allegations or the prophet for any judicial outcome for the ongoing litigations, but we must listen to Aetna at this time to find out what are avoidable and preventable or not, as these Aetna litigations represent the 2012 national landscape changes by the most payors for all out-of-network providers,” says Dr. Jin Zhou, President of, a national expert on PPACA and ERISA appeals and compliance.

According to the Wall Street Journal on Feb 01, 2012, “Aetna Inc.'s earnings rose 73% as the health insurer continued to benefit from light medical costs amid a sluggish pace of patient visits to hospitals and doctors' offices.” (

According to the report from Crain's New York Business on Feb. 07, 2012, Edward Neugebauer, Aetna's head of litigation, is quoted as saying, “By spreading the cases out across the country, Aetna is using litigation 'as a stepping-stone to open policy doors' at the state level.” (
“LATEST NEWS: Aetna Accuses New York Doctors of Overcharging Patients

“Aetna made headlines in California last week when it sued seven California surgery centers for treating patients at out-of-network rates, charging $66,100 for a bunion repair. But in New York, Aetna quietly filed a lawsuit last October against New York doctors whose patients were socked with massive bills—in one case for more than $425,000.

"The two lawsuits, along with earlier ones filed in New Jersey and Texas, form a strategy by Aetna to combat what it sees as abusive out-of-network charges by providers, according to Crain's Pulse."

Also as reported in the report from the Crain's New York Business on Feb. 07, 2012, Aetna complained against the provider’s failure to disclose the referral to out-of-network (OON) and OON UCR charges, and threatening to balance bill patients for unpaid claims (
“The doctors did not clearly communicate the charges to Aetna patients, Aetna alleged […]

"Through a billing company, Business Dynamics, Hishmeh threatened to bill patients for the portions of the bills unpaid by Aetna, according to the lawsuit.”

According to the Bloomberg Businessweek on Feb 6, 2012, Aetna sued seven OON California surgery centers for allegedly not collecting or waiving co-insurance from the patients (
“Bunion Repair at $66,100 Spurs Aetna Lawsuit Against Clinics

"Feb. 3 (Bloomberg) -- Aetna Inc. is suing seven California surgery centers for a billing system that it claims “recklessly subverts” health care delivery with charges of as much as $66,100 for a bunion repair.

"The lawsuit seeks to stop the centers from waiving the co-insurance payments people are supposed to be charged when they use doctors or facilities that don’t have contracts with their insurers. By not requiring such payments for so-called out-of- network care, the centers illegally lured patients, and then billed Aetna up to 2,500 percent more than what the company pays its contracted providers for procedures, according to the suit.”

The court case info: Aetna Life Insurance Co. v. Bay Area Surgical Management LLC, File 02/02/2012, Case #: 112CV217943, The Superior Court of California, County of Santa Clara.

Aetna TX case info: AETNA HEALTH INC vs. SOFOLA, IFEOLUMIPO O (MD) (Case #: 2011-73949 / Court 152), Harris County, Texas.

“Obviously, if not collecting or waving co-insurance in CA and TX, but collecting or balance billing for unpaid claims in NY & NJ, the OON providers may get sued both ways. Aetna may or may not prevail in the court for these allegations, but we must find out the ways for why and how the providers may not get sued in either ways,” said Dr. Zhou. “That is why providers must listen and watch timely and closely, when the out-of-network healthcare earthquake is already here.”

This new executive Webinar will discuss the following topics:
1.    Why and how the waiver of deductible and co-insurance may be questionable practice, subject to the payor’s legal challenges in the court and SIU investigations, and how to avoid them with compliant policies and practice;
2.    The compliant policies and practice for proper disclosures, for the patients to make informed decisions in exercising freedom of choice for the OON providers, solely based on the quality and safety of the care and reputations of the providers.
3.    OIG: Fraud and abuse prevention brainstorming. (
4.    DOL: About 77% of Insured Americans Purchased Out-Of-Network Coverage in Private Industry (BLS, NBS 2010, page 11 of 167):
5.    PPACA & ERISA Compliant Appeals and litigation avoidance and/or support.
6.    DOL: PPACA & ERISA Claims Regulations Assistance and Complaints Webpage

To find out more about PPACA Claims and Appeals Compliance Services from

Located in a Chicago suburb in Illinois, offers free webinars, basic and advanced educational seminars and on-site claims specialist certification programs for doctors, hospitals and commercial companies, as well as numerous pending national ERISA class action litigation support. Dr. Jin Zhou is regarded as the industry “Godfather of ERISA claims” for healthcare providers.

For any questions, please contact Dr. Jin Zhou, president of, at 630-808-7237.


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