Aetna has accused a surgeon, his wife and affiliated clinics of pumping up bills by having patients start at in-network hospitals, then sending the patients to out-of-network affiliates for many services from February 2022 through April 2026.
Once the patients were at the out-of-network affiliates, the affiliates billed Aetna at high out-of-network rates, according to a complaint Aetna filed June 5 in the U.S. District Court for the District of New Jersey.
The affiliates made the high rates stick by using the No Surprises Act independent dispute resolution system to approve the claims, Aetna told the court.
The defendant, Dr. Amita Poonia, his wife and the clinics used the arrangement to collect payments that were more than $50 million higher than what Aetna would have paid if the claims had been filed as ordinary in-network claims, Aetna said.
The No Surprises Act IDR system is supposed to provide a neutral service that can settle some types of claim fights between insurers and providers. System critics say IDR entities have sided with the doctors in about 88% of the disputes filed.
The clinics listed along with Poonia as defendants include surgery centers, pain management centers and an anesthesia group practice.
Aetna and Poonia could not immediately be reached for comment.
The backdrop: Physicians and hospitals argue that health insurers often pay too little to keep hospitals in business or make it worth physicians' time to continue to work in medicine.
Health insurers and administrators of employers' self-insured health plans contend that aggressive provider billing has been leading to a big, unexpected surge in claims since about 2024.
The complaint: Aetna has accused the defendants of 10 types of violations of federal and state laws and is asking for a jury trial.
The counts include fraud, violation of the state and federal Racketeering Influenced and Corrupt Organizations Act laws, conspiracy to violate RICO and "tortious interference with contracts."
In one case described in the complaint, a clinic affiliated with Poonia billed Aetna for $43,500 for an out-of-network service. An in-network Aetna provider would have normally received $353.77 for the same service, according to Aetna.
In another case, Aetna was billed $25,478.16 for a service that should have cost $75.28, according to Aetna's market fee schedule.
"But for defendants; material misrepresentations regarding the payability of the out-of-network claims, Aetna would have properly denied the out-of-network claims in their entirety and would not have paid tens of millions of dollars to the out-of-network defendant," according to the complaint.
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