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...

The Top 10 Health Technology Hazards
ASC Administrator Claims Docs Forced Her Out After She Investigated Claims of Sexual Harassment Against Them
FDA Recommends Black Box Warning for Power Morcellators
California Pain Doc Settles Fraudulent Billing Charges for $1.2M
Alabama Hospital Files Suit to Halt Construction of Competitor's ASC
Doris Parker, RN, Returns Today to Her Native Liberia to Help Curb Ebola
Participation High in Medicare's ASC Quality Reporting

 
Have an account? Please log in:
Email Address:
  Remember my login on this computer

DID YOU SEE THIS?
Infection Control

Endoscope Cleaning Made Fast, Safe And Efficient

advertiser banner

Other Articles That May Interest You

Covidien Wins $176.5M Patent Infringement Verdict

Federal court upholds company's ultrasonic technology claims.

N.J. Revokes License of Spine Surgery Anesthesiologist

Legal Update - Office-Based Suites Forced to Forfeit Facility Fees

Many insurers are auditing office-based surgery suites and asking for givebacks.