Aetna Hit With Counterclaims By Hospital

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Hospital believes Aetna’s lawsuit is part of a “scheme to sue out-of-network providers throughout the nation to coerce them into financially burdensome in-network contracts with Aetna.”

Aetna hit with counterclaims by ‘hotel-like’ hospital in $120M kickback lawsuit

Written by Ayla Ellison (Twitter | Google+)  | August 13, 2015

North Cypress (Texas) Medical Center has made allegations against Aetna Life Insurance in its answer to a billing fraud and kickbacks lawsuit that Aetna brought against the hospital earlier this year.

In February, Aetna brought a lawsuit against North Cypress alleging the physician-owned community hospital engaged in an illegal kickback scheme and used deceptive billing practices that led Aetna to overpay the hospital by as much as $120 million.

According to Aetna’s complaint, the hospital’s annual gross revenues exceed $1.5 billion a year — “an amount that is more than twice that of other nearby hospitals that have substantially more patient volume and provide a wider array of medical services.” Aetna alleges North Cypress achieved its financial success through a fraudulent billing scheme with Robert Behar, MD, CEO of North Cypress, acting as the mastermind.

The scheme allegedly involved North Cypress engaging in a number of illegal acts, including paying kickbacks to physicians for patient referrals and using improper billing techniques. In addition, by charging exorbitant fees, Aetna alleges that North Cypress was able to advertise its facility as having “an upscale five-star hotel-like ambience.”

Through the hospital’s use of fraudulent billing methods and allegedly orchestrating an out-of-network business strategy, Aetna claims it has overpaid North Cypress as much as $120 million since Jan. 1, 2009.

However, North Cypress has denied the allegations brought against it. Karen Hinton, a spokesperson for North Cypress, previously told Becker’s Hospital Review that the hospital believes Aetna’s lawsuit is part of a “scheme to sue out-of-network providers throughout the nation to coerce them into financially burdensome in-network contracts with Aetna.” The hospital has now formally made those claims against Aetna.

In a 35-page fraud and Racketeer Influenced and Corrupt Organization Act suit, North Cypress and Dr. Behar allege Aetna and four of its officers, including Aetna CEO Mark T. Bertolini, instigated a decade-long scheme against physician-owned, out-of-network providers across the nation, including North Cypress. The hospital claims the purpose of the scheme is to “bring down, destroy and bankrupt those entities so that Aetna can make more money.” North Cypress specifically alleges that Aetna makes what it calls additional “contingency fees” from denying claims to physician-owned, out-of-network providers.

An Aetna spokesperson, Anjie Coplin, told Becker’s the claims made by North Cypress and Dr. Behar are a “transparent attempt to hide their outrageous tactics of taking advantage of patient and employer health plans for profit.” She said the RICO claim against Aetna has already been dismissed in related litigation, and this latest RICO claim “shows how desperate Dr. Behar, North Cypress and their attorneys have become in recent months.”

Editor’s Note: This article was sent to us this morning with a note: 

“Interesting business practice, Aetna overpays with someone else’s money due to lack of diligence, years later they go back and recover the money yet even though it’s their clients money that was overpaid in the first place, Aetna has a contractual right to keep between 50% to 100% of the recovery.”
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From Mike Dendy, CEO of AMPs:

Interesting. Aetna auto-adjudicates almost all their claims so they overpaid a hospital (with their clients money) by over $120mm and now after 6 years they are wanting that money back? When employers try to implement external hospital review services (like AMPS) with Aetna and other large payers they scream bloody murder that such is not allowable under their contracts. What will Aetna do with the money if it is recovered? Check your large payer contract. There’s a good chance that your administrator (Aetna, United, BC/BS, Cigna) has a contractual right to keep some or all of it.

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