Aetna, a subsidiary of CVS Health, has initiated legal proceedings against Radiology Partners, accusing the organization of orchestrating a “multiphase healthcare fraud scheme” that breaches the No Surprises Act (NSA). The lawsuit, filed on December 23 in the U.S. District Court for the Middle District of Florida, alleges that Radiology Partners misled Aetna and its affiliated plan sponsors, resulting in substantial financial losses due to fraudulent medical claims in Florida.
According to the lawsuit’s claims, Radiology Partners exploited the name and tax identification number of medical group practice Mori, Bean and Brooks (MBB) to submit bills for services rendered by various affiliated radiology groups across Florida, thereby misrepresenting the identity of the actual service providers. Aetna’s legal team argues that this deceptive practice caused the insurance company to overpay for identical services administered by the same physicians in the same healthcare facilities.
The laws in question, particularly the NSA, mandate that out-of-network providers like MBB follow specific rules regarding arbitration for underpaid claims. Aetna alleges Radiology Partners knowingly submitted false certifications in their arbitration processes, misleading various entities including Aetna itself and the U.S. Department of Health & Human Services. The suit claims that Radiology Partners and MBB improperly initiated arbitrations for services provided by non-MBB providers who were ineligible under the NSA.
In response, Radiology Partners asserted that its billing practices adhere to all standards of healthcare regulations, positioning Aetna’s legal challenge as a reaction to its poor reimbursement practices. The company highlighted that MBB has achieved a high success rate—98%—in NSA arbitrations, suggesting that Aetna’s claims may lack merit. Radiology Partners expressed a desire to negotiate an in-network agreement with Aetna, emphasizing that their previous attempts have not yielded results.
This lawsuit is not an isolated incident as Radiology Partners had previously faced similar accusations from UnitedHealthcare, which in 2023 alleged that the company engaged in a pass-through billing scheme resulting in significant fraudulent payments.
Aetna is seeking to nullify any arbitration awards it believes were fraudulently gained, as well as an injunction to stop Radiology Partners and MBB from continuing what the suit characterizes as deceptive arbitration practices under the NSA.
The ongoing legal disputes in the healthcare sector highlight the complexities surrounding insurance reimbursement and the challenges faced by both payers and providers. These developments could lead to greater scrutiny and potential reform in billing practices and the arbitration process.
In summary, Aetna’s lawsuit against Radiology Partners addresses serious allegations of healthcare fraud. This case underscores the importance of transparency in medical billing and the need for equitable practices that protect both patients and insurance providers from fraudulent activities. As the litigation unfolds, it will be intriguing to see how both parties navigate the complexities of the healthcare system and the potential implications this may have for future healthcare practices and policies.