Edward $, Wardell, Esquire (017181976) Thomas Vecchio, Esquire (042192004) CONNELL FOLEY LLP 45? Haddonfield Rood, Site 250 Cherry Fil, New Jersey 08002 (655) 317-7100 Attorneys for Plaintiff ‘Aetna Health Ine. "AETNA HEALTHING, individually andin | the interest ofits members; Plaintiff ‘SUPERIOR COURT OF NEW JERSEY ‘CHANCERY DIVISION / OCEAN COUNTY DOCKET NO: OCN-C- Civil Action ‘COMPLAINT FOR DECLARATORY ‘AND INJUNCTIVE RELIEF SANJAY BHAGAT, MD. Defendant, Plaintiff Aetna Health Inc. (“Aetna”) files the following Verified Complaint against Defendant Sanjay Bhagat, M.D. ("Defendant” or “Bhagat”. 1. INTRODUCTION 1, Aetna brings this action against Defendant for declaratory and injunctive relief, to declare that his charges for services are unlawful and unenforceable; to enjoin him from submiting health insurance claims for unlawful and excessive fees to Aetna or beneficiaries of its health benefit plans; and to enjoin him from balance billing Aetna beneficiaries for those ‘unlawful and excessive fees. 2. Defendant isa staff physician at Monmouth Medical Center, Southem Campus in Lakewood, New Jersey (Oh/a Kimball Medical Center) (the “Hospita”). Monmouth Medical ‘Center is a party to a participating provider contract with Aetna. As a staff physician, Defendantprovides inpatient evaluation and management services to patients while they are confined in the hospital, Defendant is a non-participating provider who does not have a contract with ‘Aetna, At the time a patient is admitted to these participating hospitals, the patient typically does ‘not know that Defendant is @ non-participating provider. Defendant does not disclose his non- participating status to the patient, das not enter into contract with the patient, does not advise the patent of his fe for services, and does not obtain any agreement to pay his fees. 4, After he provides services, Defendant submits health insurance claims to Aetna tnd seeks to pursue payments for unlawful exorbitant fees that he is not lawfully entitled to receive from Aetna and its members. 5. In this case, in August of 2012, Defendant provided services to an Aetna member, R.C., at Monmouth Medical Center without disclosing his out-of-network status. 6, Defendant submitted exorbitant tills to Aetna for the services provided in connection with the treatment of abdominal pain at the Hospital on or about August 6, 2012 and ‘August 7, 2012. Specifically, Defendant submitted two separate claims to Aetna for a total of $31,939.00, charges which grossly excved the fair value of his services. By comparison, Defendant's charges exceeded the Medicare reimbursement by almost $30,000 and the FAIR Health! expected charge by more than $28,000.00. FAIR Health, Ine is national, independent, not-for-profit entity established under the auspices ofthe New ‘York Antorey Gene's Office that provides recognized usa, eustomar, and reasonable charge cleultions. See ip: areal og sane7. After Aetna properly paid Defendant the fair value of his services and the saveepted rate for similar services in the community by providers in Defendant's area of practice, ‘Defendant sought to exploit and 10 gouge R.C. by biling tte member for the ditference between his charges and what Actna paid to him ~ a practice commonly referred to as “balance billing.” 8. The fees charged by Defendant do not represent the fair value of his services. To the contrary, Defendant's charges are unlawful and excessive; violate the prohibition against excessive fees promulgated by the Board of Medical Examiners (N.J.A.C, 13:35-6.11); and are not supported by any agreement between Defendant and R.C. 9, As a result, Actna is entitled to declaratory and injunctive relief which enjoins Defendant from pursuing these fees from Aetna or its members, and from placing its members “in the middle” to coerce payment ofthese excessive fees 1 THE PARTIES 10, Plaintiff Aetna Health Inc. (“Aetna Health’) is a New Jersey corporation duly authorized to transact business in this state. At all times material hereto, Aetna Health, among ‘other things, provided health care benefits and insurance to members, and paid health care insurance claims on behalf ofits members. Aetna Health actually does business in this county 11, Defendant is a physician licensed to practice in New Jersey with a primary practice address of 110 Prospect Street, Lakewood Township, New Jersey 08701. At all times material hereto, Defendant submitted health insurance claims to Aetna for medical services rendered to individuals who received health care benefits and/or health insurance provided by ‘Aetna.II. VENUE AND STANDING 12, Venue is placed properly in this County because the parties reside in and do ‘business inthis County 13, Aetna has stnding to sue Defendant forthe sub insurance claims to Aetna and tothe beneficiaries of ts benefit plans because it has an adversary interes to Defendant inthis dispute. Upon information and belie, Defendant has thretened to file legal actions to collect these unlawl charges from RC unless the unawfol carges are prin ul 14, Aetna has sanding to seck declaratory and injunctive rei to enjoin Defendant from submiting unlawful health insurance claims to Aetaa and it insureds inorder to protect its own provider network and benefit plans and to prevent Defendant rom interfering with is relationships with plan beneficiaries. In addition, Defendant's submission of claims for unlawfil and excessive charges undermines Actne’s ability to deliver benefits to plan beneficiaries and to contol the costs of eare under its plans IV. DEFENDANTS SUBMISSION OF HEALTH INSURANCE CLAIMS FOR UNLAWFUL AND EXCESSIVE FEES A. ‘The Health Insurance Benefits Provided by Aetna 15, Aetna provides health care insurance and benefits to beneficiaries pursuant to a varity of health care benefit plans and policies of insurance, including inividal health benefit plans, employer-sponsored benefit plans, and government-sponsored benefit plans. Actna's benefit plans provide covered benefits for in-network services rendered by participating providers who contracted with Aetna and for out-of-network services rendered by non participating providers who have not contracted with Aetna, asian1 Tn.Network Benefits by “Participating” Providers 16, Aetna provides “in-network” health care benefits to its subscribers through a network of “participating” medical providers who have entered into contracts with Aetna to. render services to subseribers in return for fees set by the terms of the cortract. 17. Medical providers who enter into contacts with Aetna are commonly knowm as “participating” providers, and the contracts between Aetna and participating providers require the participating provider to accept negotiated payment for services as payment in full and prohibit the provider ftom seeking additional payments from the patient. The subscriber ‘ordinarily has no financial obligation to the participating provider beyond a small, fixed copayment. 18, The agreements between Aetna and its participating providers allow Aetna to deliver health care benefits ficiently through its provider network, to anticipate and control the cost of care, to reduce its financial risk for insured plans, and to reduce the financial risk faced by subscribers for health care services. 19, Beneficiaries have ready access to participating providers. Aetna publishes «directories of participating providers to its subscribers Who consume health care services in New Jersey. Subscribers may obtain medical services from these providers with little or no financial risk or out-of-pocket expense. 2. “Out-of- Network Benefits by “Non-Participating” Providers 20. Aetna provides health benefit plans and policies of insurance that provide “outof- network” benefits for services rendered by “non-partcipating” providers who have not entered ‘nto contracts with Aetna and have not agreed to accept negotiated payments as payment in full for services rendered, casi21, The fees charged by non-panticipating providers are set by an agreement or relationship with the patient subject to the laws and regulations which govern the practice of ‘medicine in New Jersey. At the time of admission to the Hospital, a patient typically does not ‘know thet Defendant is « non-participating provider. 22. Aetna benefit plans and policies of insurance that cover services by non- participating providers may limit the benefits available for out-of-network services and require subseribers to contribute tothe costs of eare by non-paricipating provides. 23. Aetna reimburses eligible charges for out-of-network services atthe lesser of the provider's actual charge for services or an amount determined by Actna pursuant to the terms and conditions ofthe benefit plan. When non-participating providers submit health insurance claims to Aetna for Aetna insureds, the charges for services rendered must represent charges that ‘were actually agreed to by the beneficiary and thatthe patent was obligated to pay. Aetna as ro obligation to cover charges for services that are not actually incurred by the plan's beneficiary 24. Pursuant to the terms ofthese benefit plans and policies of insurance, the patent or beneficiary is responsible for payment of charges which are not covered by the plan or exceed the amount ofthe reimbursement paid by Aetna. The amount by which the provider's charge exceeds the amount payable under the plan is refered to as the “balance bill” 25. In order to pursue a patient for any charge, the provider must have a valid and ‘enforceable agreement with the patent to pay the charge and cannot charge fees that are excessive, NJAC. 13:35-6.11.B. Defendant's Submission of Health Insurance Claims to Actna 26. Defendant submitted health insurance claims to Aetna to obtain payment for inpatient services rendered to R.C. while he was confined te the Hospital, 27. Before he provided the services billed to Aetna, Defendant did not disclose his. non-partcipating status to R.C., did not enter into a contract with him, did not advise R.C. of his fee for services, and did not obtain any agreement to pay his fees. In addition, any such agreement would be unlawful and unenforceable because i imposes excessive charges for services on R.C. in violation ofthe laws governing the pracice of medicine in New Jersey. 28. In the absence of an agreement, a physician can recover no more than the fait value of his services in the community and must prove that its charges are reasonable and customary and within the range customarily charged to patients for such services by medical providers practicing in the relevant field or specialty within the community. 29. The Board of Medical Examiners further prohibits a licensee, like Defendant, from charging excessive fees for services, NJLA.C. 13:35-6.11 30. Under N.JA.C. 13:35-6.11(b), a “fee is excessive when, after a review of the facts, a licensee of ordinary prudence would be left with a definite and firm conviction thet the {ec isso high as to be manifestly unconscionable or oventcaching under the cicumstances.” 31. Under NJAC. 13:35-6.11,“{ulnless services are proved during an emergency or other circumstances where opportunity, custom and practice will preclude discussion prior to the rendition of such services, the licensee shall, in advance of providing services, specify or discuss and agree with the patent, the fee or basis for determination of the fee to be charged.” 32." RC. was allegedly treated for abdominal pain at the Hospital on or about August 6, 2012 and August 7, 2012.33. During R.C.'s stay, Defendant allegedly performed and submitted two separate claims to Aetna under CPT codes 99285 and 43239 for August 6, 2012 and CPT codes 45380 and 44360 for August 7, 2012 for a total of $31,939.00. These charges vastly exceed the fair value of the services rendered and violate the prohibition on excessive fees outlined by the Board ‘of Medical Examiners 34, Aetna processed the claim and paid Defendant $1,291.50 forthe services rendered fon August 6, 2012 and $1,238.85 for the services rendered on August 7, 2012. The claims processed represent the total fair value and reasonable charge for the services less the patient's coinsurance of ten percent (10%) for inpatient hospital services. As such, pursuant to the plan, RC. is only responsible fora total of $281.15 in coinsurance. 35. Defendant is now seeking to collect the balance of his excessive charges in the amount of $10,635.50 or more directly from R.C. and is harassing him with repeated, continued contacts in an effort to collect his unlawful charges. 36. In violation of New Jersey law, Defendant did not specify, discuss or reach an agreement with R.C, on his fe or the basis for his charges. 37. The charges submitted by Defendant are excessive, manifestly unconscionable ‘and overreaching. Nothing in the nature and cireumstances of the services rendered by Defendant justifies the charges submitted to Aetna, 38. Unless enjoined, Defendant's conduct will ireparably harm Aetna, its provider networks and its member, R.C.COUNT ONE Declaratory and Injunctive Relief 39, Aetna repeats and incorporates herein by reference the allegations contained in Paragraphs 1 trough 38 ofthis Complain. 40. Defendant submitted health insurance claims to Aetna forthe services described in Paragraphs 32 ~ 33 above knowing that he did not specify, discuss or inform R.C. of his charges fo services 41, Defendant submitted health insurance claims to Aetna for the services even ‘though he did not have a valid agreement with R.C. 42, Inemergent circumstances or in the absence ofan agreement, Defendant can only recover the reasonable value of his services within the community in which he practices. 43. Defendant's claims to Aetna included charges that are excessive and violate NJAC. 13:35-6.11 because the charges were not related to the time and effort required; the novelty and difficulty ofthe provedure or treatment; the skill required to perform the provedure for treatment properly; any requirements or conditions imposed by the patient or by the ‘circumstances; the nature and length of the professional relationship with the patient; the ‘experience, reputation and ability of the licensee performing the services; the nature and circumstances under which services are provided and common la, 44, Upon information and belief, in onder to coerce Aetna to pay his unlawful and excessive charges, Defendant has threatened and continues o threaten to file suit aginst R.C., even though he knew his charges were unlawful, void and unenforceable. 45, As a result of Defendant's unlawful submission of heath insurance claims for excessive fees Aetna has suffered and will continue to suffer damages and irreparable harm,46. As aresutof Defendants unlawful conduct, Acta is entitled to a declaration that Defendant's fees are unenforceable, exceed the reasonable value of his services, and are excessive, void and unenforceable in violation of NILA. 133546.11. 47. As a result of Defendant's unlaweul conduct, Aetna is ented to a permanent injunction prohibiting Defendant fom charging R.C. or any otber Aetna insureds excessive fees in violation of New Jersey law and from submiting claims to Actaa for charges that are ‘excessive and which were not agreed upon by the plan beneficiary. WHEREFORE, Acina demands judgment in its favor and against Defendant for declaratory and injunctive relief prohibiting him from charging RLC. or any other Aetne insureds excessive fees in violation of New Jersey law; from submitting claims to Aetna for charges that are excessive and which were not agreed upon by the plan beneficiary; and from attempting to collect from R.C. or any Aetna member any amounts prohibited by law and for such other relief as the court determines is appropriate. CONNELL FOLEY LLP Attorneys for Plaintiffs ‘etna Health Ine. By: DATE: October 31, 2014 Filson’ S Wardell Faquive ‘Thomas Vecchio, EsquireCERTIFICATION PURSUANT TO RULE 4:5-1 Pursuant to Rule 45-1, the undersigned hereby sates on behalf of the Plant in this action, that the matter in controversy isnot the subject ofan other action pending in any other ‘Court or pending arbitration proceeding tothe best ofthis party's knowledge or belief nr is any such other action or arbitration proceeding contemplated. Further, other than the parties set forth in this pleading, this party is aware of no othe person or entity that should be joined inthe above action. In addition, it is recognized that itis the continuing obligation of each party to file and serve upon all parties and the Court an Amended Certification if there is a change inthe facts as stated inthis original Certification CONNELL FOLEY LLP Attorneys for Plaintiffs ‘Aetna Health Ine. By: DATE: October 31, 2014 Edward S, Wardell, Esquire ‘Thomas Vecchio, EsquireDESIGNATION OF TRIAL. COUNSEL. Pursuant to R. 4:25-4, Edward S. Wardell, Esquire is hereby designated as tral counse! fr Plaintiffs Aetoa Health Ine, (CONNELL FOLEY LLP Attorneys for etna Health Ine » & OL DATE: October 31, 2014 Baward S, Wardell, squire Thomas Vecchio, Esquire