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Aetna Sues NJ ASC Over Out-of-Network Practices

Insurer claims it has overpaid $10M as a result

Published: May 22, 2013

Aetna has sued a New Jersey ASC for "damages and treble damages based upon fraudulent and excessive billing," according to a filing in U.S. District Court for the District of New Jersey. The insurer claims it has overpaid Patient Care Associates, LLC, by $10 million as a result of PCA's "regularly submitt[ing] false and fraudulent health insurance claims … which misrepresent and inflate the actual charges for out-of-network services," says the suit.

According to court documents, physicians, some of whom hold financial interests in PCA, referred Aetna-covered patients to the ASC even though it's a non-participating center. "PCA and the physicians encourage patients to use PCA rather than a participating center and assure the patients that they will not be liable for any charges associated with the inappropriately charged out-of-network costs," says the suit.

Aetna claims that, from January 2010 to June 2012, it paid PCA approximately $10 million for these out-of-network procedures. The suit cites examples of what Aetna considers to be inflated charges: In May 2012, PCA submitted a bill for $83,778 for a knee arthroscopy (reimbursed at $6,973 by Medicare); in November 2011, PCA charged Aetna $193,831 for facet joint injections and ended up being paid $95,347 of that (Medicare reimbursement for the procedure is $405.90). The insurer is seeking to recover the overpayments, pre- and post-judgment interest, damages, lawyer's fees and costs of the suit.

A representative at PCA reached by phone said the facility had no comment. Request for comment from Aetna's legal representation was not returned.

Stephanie Wasek

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