While more payers and providers are trying to pursue value-based reimbursement models, some insurers are finding themselves fighting back against questionable fee-for-service schemes.
Aetna is recouping $8.4 million from a small hospital and three clinics for two years worth of overcharges.
This month, a federal judge in Texas ruled for Aetna in its allegations that freestanding emergency clinics Trinity Healthcare Network, ER DOC 24/7 and Premier Emergency Room & Imaging claimed a non-existent affiliation with Cleveland Imaging & Surgical Hospital, a four-bed facility in eastern Texas, in order to charge much higher fees, which resulted in Aetna being overbilled by $9.3 million over the course of two years.
According to court documents, Cleveland Imaging & Surgical Hospital, which opened in 2006, let the clinics use its provider number in exchange for about 15 percent of the reimbursement the clinics received per bill.
"Using the hospital's number made it look like the clinics' treatment happened at a full-service hospital, rather than an unlicensed clinic," wrote U.S. District Judge Lynn Hughes in Houston.
Though the clinics were not licensed to bill for a range of 17 different facility-based fees permitted under Texas law, the owners argued in court that their billing was lawful based on the arrangement with the licensed hospital.
Billing under a hospital's license would have been permissible under state law if the clinics were owned by the hospital. The clinics are separate organizationally from the hospital, although three of the hospital's five owners (Ravi Moparty, MD, Fadi Ghanem, MD, and Khanh Le, MD) have partial stakes in Premier Emergency Room & Imaging, which has since closed.
"The billing contract cannot change the objective reality that the clinics are independently owned offices – offices not qualifying to be rated hospitals," Hughes wrote.
"If these clinics want to charge higher fees, they need to become a licensed hospital, not craft devious, inauthentic billing contracts to make it appear as though they have become part of the hospital," Hughes wrote.
The ruling only addressed part of Aetna's lawsuit. Still to be resolved are accusations by the insurer of fraud, negligent misrepresentation and civil conspiracy.