Aetna, part of CVS Health, is suing Radiology Partners for what Aetna’s legal team is calling a “multiphase healthcare fraud scheme” that violates the No Surprises Act (NSA).
The lawsuit, filed December 23 in the U.S. District Court, Middle District of Florida – Jacksonville Division, alleges that Radiology Partners defrauded Aetna and its plan sponsors out of tens of millions of dollars through fraudulent medical claims in Florida.
“This was a purely profit-driven scheme and, upon information and belief, motivated by Radiology Partners’ greed and desire to gin up additional revenue to satisfy the demands of its private equity owners,” the lawsuit says.
The suit states that phase one of the scheme saw Radiology Partners identify medical group practice Mori, Bean and Brooks (MBB) as having lucrative in-network contracts with commercial payors in Florida, including Aetna. Radiology Partners began using MBB’s name and tax identification number (TIN) to bill for services performed by all its affiliated Florida radiology groups, the suit continues.
“Radiology Partners’ use of MBB’s TIN to bill for services performed by other radiology groups misrepresented that MBB — as opposed to another radiology group with its own separate in-network contract — performed the services billed,” according to the suit.
The suit also alleges that Radiology Partners caused Aetna and its plan sponsors to pay more for the same services provided by the same physicians at the same hospitals. MBB’s claims were subject to the NSA since the practice is an out-of-network provider. The suit also alleges that Radiology Partners knowingly provided false certifications to Aetna, arbitrators, and the U.S. Department of Health & Human Services in initiating each arbitration.
“Radiology Partners and MBB are violating the No Surprises Act by initiating arbitrations on behalf of MBB for services rendered by non-MBB providers, including providers who are expressly ineligible to participate in arbitrations under the No Surprises Act,” the suit states.
Radiology Partners issued its own statement since the suit was filed, saying that its owned and affiliated practices comply with all applicable healthcare laws, regulations, and ordinary business practices.
“Aetna’s actions appear to reflect a broader response to its terrible track record for reimbursing medical practices under the federal [NSA],” the company said in its statement. “Aetna’s complaint failed to mention that MBB has a 98% win rate through NSA arbitration, which is determined by independent, third-party arbiters reviewing underpaid, out-of-network claims from Aetna.”
Radiology Partners continued by saying that MBB turned to the NSA arbitration process for underpaid services that MBB provided to its members. It added that Aetna has not negotiated a contract to return to in-network status for employers and members.
“We view this as an embarrassing waste of healthcare resources and would much prefer to be in network with Aetna, as we are with the vast majority of payors,” Radiology Partners stated. “We have communicated this to Aetna countless times over the last two years.”
This isn’t the first time Radiology Partners has been accused of fraudulent billing by a payor. UnitedHealthcare in 2023 sued the company, accusing it of orchestrating a pass-through billing scheme resulting in tens of millions of dollars in allegedly fraudulent payments.
Aetna is seeking a vacating of the arbitration awards it claims were fraudulently obtained, an injunction preventing Radiology Partners and MBB from continuing to file what Aetna is calling fraudulent arbitrations under the NSA independent dispute resolution process, and damages and other relief requested.