Jacksonville, Florida – Health care giant Aetna has filed a lawsuit in the U.S. District Court for the Middle District of Florida with Radiology Partners and its affiliate Mori Bean & Brooks (MBB) for allegedly paying high medical bills. A lawsuit was filed against him for orchestrating a large-scale medical fraud scheme. The company and its plans have tens of millions of dollars in sponsorship.
The lawsuit, filed in late December, alleges that Radiology Partners, a private equity-backed radiology group, and MBB engaged in a multi-step scheme that included fraudulent billing practices and abuse of the federal Surprise Act (NSA) arbitration process. claims to have been involved.
“Through this fraud, the defendants caused Aetna and its plan sponsors to pay significant amounts of money.” same Services provided by same doctor of same “This was a purely profit-driven scheme,” the lawyers wrote in the complaint.
Suspicion of fraudulent billing
According to the complaint, Radiology Partners acquired MBB in 2018 and soon began using MBB's Taxpayer Identification Number (TIN) to bill Aetna for services provided by other radiology groups throughout Florida. I started. Although these groups had their own contracts with Aetna, billing through MBB allegedly allowed the radiology partners to exploit higher reimbursement rates. The lawsuit alleges that the misrepresentations caused Aetna to pay higher amounts for the same services, resulting in more than $20 million in improper payments as a result of the scheme.
The complaint details how Radiology Partners used tactics such as jacking up billing rates and taking advantage of MBB's contracts to maximize profits. In one example, a routine chest x-ray billed under another radiology group cost Aetna $14.50, but when billed under MBB's TIN, it jumped to $252.12; This is an increase of over 1,600%.
Suspicion of abuse of the Surprise Prohibition Act
After MBB's contract with Aetna ends in 2022, Radiology Partners will seek out-of-network efforts to further exploit the NSA, which protects patients from unexpected medical bills and establishes an arbitration process for billing disputes. It is said that the company has moved to billing operations. Aetna alleges that Radiology Partners used bulk claims to overwhelm Aetna and secure higher payouts, filing tens of thousands of arbitrations with the NSA for services that were not otherwise eligible.
The complaint alleges that these tactics resulted in excessive arbitration awards against radiology partners, reinforced by data manipulation and certification misstatements.
Adjusted scheme
The complaint describes Radiology Partners as the mastermind behind the alleged scheme, with the help of private equity backers. The company reportedly controlled a related radiology group while hiding these relationships to appear compliant with state regulations prohibiting corporate activity in the medical field.
Aetna also accused Radiology Partners and MBB of taking extreme measures to cover up the plan, including misleading hospitals and creating false affiliations between radiology groups. .
Broad impact on healthcare costs
Aetna alleges that the fraud has significantly increased health care costs without improving the quality of care across Florida.
Insurers argue that the program is consistent with broader concerns about the influence of private equity in health care, citing the Federal Trade Commission's (FTC) case against U.S. Anesthesia Partners as a comparative example of private equity-driven consolidation and exploitation. ).
What's next?
Aetna is seeking compensatory and punitive damages, restitution of unjustified payments, and an injunction to prevent Radiology Partners and MBB from continuing these practices. The company is also asking the court to set aside an arbitration award it obtained over alleged fraudulent claims.
The case highlights growing tensions between health care providers and insurance companies over billing practices and the growing influence of private equity in the health care sector.
A high-stakes legal battle
This case represents one of the most significant legal issues surrounding the Anti-Surprise Act since it went into effect. With millions of dollars and medical industry practices at stake, the case will be closely watched by regulators, policy makers, and industry players alike.
Radiology Partners responded to the allegations, calling the lawsuit “unanticipated.” The group strongly disputes Aetna's allegations and stands by the integrity of its owned and affiliated operations. The statement reads in part:
“This case exemplifies Aetna's conscious strategy of exploiting legal disputes rather than seeking fair resolutions. However, I don't want to pay if I lose. They want a judge to say they don't have to pay claims from disputes that have already been decided, and they want to eliminate the unnecessary and unusual costs of NSA arbitration by paying higher premiums to employers and ultimately They seem content to leave the burden to the union members.”
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