Court dismisses Aetna fraud case against Radiology Partners

A federal judge in Florida has dismissed Aetna’s fraud lawsuit against Radiology Partners and Mori, Bean and Brooks. The case centered on No Surprises Act independent dispute resolution awards involving radiology claims in Florida.

The lawsuit was filed by Aetna Health, Aetna Life Insurance, and Aetna Health Insurance in the U.S. District Court for the Middle District of Florida. Radiology Partners and Mori, Bean and Brooks were named as defendants.

Aetna alleged that after Radiology Partners acquired Mori, Bean and Brooks, claims from other Florida radiology practices were routed through Mori, Bean and Brooks to obtain higher reimbursements. The court noted that Aetna terminated Mori, Bean and Brooks’ in-network contract after claim submissions increased.

After the contract termination, Aetna alleged that other Radiology Partners practices continued submitting claims through Mori, Bean and Brooks as out-of-network claims. The complaint alleged that this led to higher payment through the No Surprises Act IDR process.

Aetna sought to vacate IDR awards, recover fees tied to arbitration participation, and limit disputed claims not yet filed through IDR. Radiology Partners and Mori, Bean and Brooks moved to dismiss the amended complaint.

Judge Brian J. Davis said Aetna had sufficiently alleged that claims were fraudulently submitted as out-of-network claims. But the court found that Aetna did not meet the standard needed to challenge the IDR awards after arbitration.

“While a close call,” the court said Aetna had not established enough basis to excuse its failure to raise the issue during the IDR process.

The court found that Aetna knew about the alleged billing practice before or during arbitration. It said Aetna’s knowledge was fatal to its position because the alleged fraud was discoverable through due diligence.

Davis also rejected Aetna’s remaining claims. The order said allowing Aetna to recover the difference between IDR awards and what it otherwise would have paid would have the same effect as discarding the administrative process established by Congress.

The amended complaint was dismissed with prejudice because amendment would be futile, according to the order. The court directed the clerk to close the case.

Aetna has appealed. A notice of appeal was filed May 6 and docketed May 8 in the U.S. Court of Appeals for the 11th Circuit, according to Justia.