advertiser banner advertiser banner advertiser banner
Digital Issues

Home >  News >  May, 2013

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

Also in the News...

Surgeon Operated on Wrong Part of Brain
Widow Sues Olympus and Custom Ultrasonics Over Husband's Superbug Death
Surgeons Reach Peak Performance Between 35 and 50 Years Old
Results From Head-to-Head Comparison of Exparel and Conventional Bupivacaine
Forbes: Punitive Ban on Physician-Owned Hospitals Imposed by the Affordable Care Act Has to Go
'Post-Hospital Syndrome' Is a Risk Factor in Elective Surgery
FDA Approval of Sugammadex Appears Imminent

Have an account? Please log in:
Email Address:


advertiser banner

Other Articles That May Interest You

Surgeons' Lounge: Employment Law

Will Fired Employees Come Back to Haunt You?

Feds Crack Down on Insurance Fraud Scheme

Florida biller's Ohio ASC scammed millions from private payors.

Feds Arrest Head Pharmacist Linked to Meningitis Outbreak