Were You Overcharged for Out-of-Network Surgery by Cigna or Aetna? Class Action Suit!

I know an attorney who is investigating whether weight loss surgery patients who had their surgery on an "out-of-network" basis may have been overcharged.  He is initially focusing on people who had Aetna or Cigna insurance at the time they had their surgery.  As I understand it, most plans will reimburse for an approved procedure that is performed out-of-network on a percentage split with the patient of the "usual and customary rate" for the procedure.  Assuming a $10,000 surgeon's bill, one would expect the insurance to pay half and the patient to pay half where the out of market is reimbursed on a 50/50 basis.  However, many insurance companies will deduct from the surgeon's bill, claiming that the charged amount is not usual and customary.  Thus, in this example, the insurance company can declare the usual and customary rate to be $8000 and only reimburse the patient $4000, which would leave the patient to pay $6000 to the surgeons. As I understand it, there may be something wrong with the way the usual and customary rate is calculated which benefits the insurance company at the expense of the patient.  For more information about this, look at this news story:  http://www.msnbc.msn.com/id/28637424/

If you would be interested in talking to him and/or serving as a class representative in a class action lawsuit, please feel free to contact him.  His name is Jeff Leon and he is with the law firm Freed & Weiss in Chicago.  His email is jeff AT freedweiss.com.  If you could describe your situation such as when and where you had the procedure, who your insurer was, what you paid out of your pocket, what the insurance paid, and the way your insurance plan was structured for out-of-network procedures, it will help him figure out if you have a claim.  These lawsuits could help a lot of future weight loss surgery patients and may even get you some of the money you paid back, even if it was years ago, although there are obviously no promises.

Just so you know, what he is investigating does not apply to (1) a denial of coverage of weight loss surgery altogether or (2) surgeries where the surgeon and hospital were "in network."

Thanks for this info, Diana.  I'm sending it to Vicki B, who the "insurance guru" on the lap-band forum, because I'm sure it will come in handy for her at some point.

Jean

It scares me to think that we will soon be dealing with socialized medicine ----- due to all of these frivalous lawsuits --- think we will get WLS then ---- I am sure we will be wishing for the private venues BACK!

Plus do these people actually get a dime of the judgment money ---- the majority of class action suits the LAWYER takes all of the money as assumed fees ???? where is the U&C there???

It is the doctors that are overcharging ----- 

You are being ridiculous.  The sanctions under Rule 11 for filing frivolous lawsuits are very steep -- this is hardly frivolous, and is based on a previous SUCCESSFUL prosecution.

Did you even read the link to the original story?  The basis for the lawsuit is that UHC set up an essentially FAKE company (Ingenix) purporting to establish UCRs.  Of course, this company was HARDLY independent, and created a database of falsely low UCRs, which UHC -- and Aetna and Cigna -- used to lowball UCRs and deny responsibility for paying surgeons their FAIR fees.

Rule 11: http://www.law.cornell.edu/rules/frcp/Rule11.htm

By presenting to the court a pleading, written motion, or other paper — whether by signing, filing, submitting, or later advocating it — an attorney or unrepresented party certifies that to the best of the person's knowledge, information, and belief, formed after an inquiry reasonable under the cir****tances:

(1) it is not being presented for any improper purpose, such as to harass, cause unnecessary delay, or needlessly increase the cost of litigation;

(2) the claims, defenses, and other legal contentions are warranted by existing law or by a nonfrivolous argument for extending, modifying, or reversing existing law or for establishing new law;

(3) the factual contentions have evidentiary support or, if specifically so identified, will likely have evidentiary support after a reasonable opportunity for further investigation or discovery; and

(4) the denials of factual contentions are warranted on the evidence or, if specifically so identified, are reasonably based on belief or a lack of information.

It's not the doctors at fault here. The insurance companies are LYING. They are claiming the "usual and customary" charges are lower than what is actually usual and customary for this service.

Class action suits do mostly benefit the lawyers in terms of money. So, if you want to get your money back that they cheated you out of, you are better off suing individually. But class action suits are a good way to make a company or industry change their ways.

Since that is needed in this case, it makes a good class action suit.

I did look at the article ----- and it states they are investigating!

And find it interesting that this lawyer is jumping right in..... and I did not see in your reply ----------is this lawyer doing this probono???

How is it that a non-par physician can think he can engorge their bills and charge outrageous fees and expect the patient to eat the cost - they know what the insurance will reimburse------ the surgeon is the one overcharging --- not the insurance .....

Example: Dr Rabkin's "agreed upon" rate is 4,000 (even at an 8 hour surgery that is still 500 per hour)   NOT TO BAD ---- what makes the other non-par surgeon worth 10,000 --------that is why the UCR rates were put in place ----- so the physicians could not bleed the insurance or patients ------

and essentially the member has the CHOICE to go to a non-par.... and prior to surgery can and should investigate what they would be responsible for --- if there choice is to still see a non-par doc...

I have heard that you are a lawyer and do not mean to offend anyone but:

I recently had a friend who's 19 year old daughter worked at a day care --- one of the children in the day care stated she was molested by another child --- because this was her room she was investigated --- she had to hire a laywer who wanted a 4,000 retainer --- he made two phone calls to " a friend" at DCF and wrote one letter --- the case was dropped and he advised her that she would still infact owed him 500.00 ---- WHERE IS THE JUSTICE HERE  --- is his rate 1,800 per hour ????? how can he justify that ----

where are the class action suits against the lawyers .....

WAIT until the insurance companys throw in the towel and the federal government takes over your will give 60% of your salary --- there will be no WLS ---- no plastic surgery afterwards???? and no more frivalous lawsuits ---

GOOD LUCK TO US ALL THEN 

There are plenty of countries with socialized medicine that pay for WLS.

I have friends in Canada and it is NOT covered...... 

He tore his ACL and waited 6 months just for his consultation and then another 8 months for surgery...

My daughter went to London and went to the ER for dizziness --- she was advised that an US of the heart would be 8 months and she would be placed on a waiting list ---- we flew her home!!!!

I hope we do not become socialized..... but will role with the punches then --- trying to get my surgery in before then LOL.....

Canada is not the only country in the world that has socialized medicine. Plus, they do cover WLS.

Not to mention, your initial premise -- that class action suits against insurance companies will bring socialized medicine to the US -- is, at best, flawed.