A federal judge has dismissed Aetna Health's lawsuit against Radiology Partners (RP) that accused the private equity-backed practice of billing fraud.
The case stemmed from higher out-of-network rates that RP was able to obtain after it acquired nine radiology practices in Florida, one -- Mori, Bean and Brooks (MBB) -- that for a time had the most lucrative in-network reimbursement contract with Aetna, according to the complaint.
Aetna responded to a surge of pricey claims routed through MBB for services performed by non-MBB practices, ultimately cancelling that contract and throwing MBB out of network, according to court records. The other practices were then able to collect higher out-of-network rates the same way through the No Surprises Act's independent resolution (IDR) process.
The April 16 filing noted that "while a close call, allegations presented in [Aetna's] Amended Complaint fail to establish a sufficient basis excusing Aetna from challenging the IDR disputes on the basis that they were wrongfully submitted by in-network providers," U.S. District Judge Brian Davis said.
The original complaint filed in December 2024 alleged that RP and MBB violated the No Surprises Act by initiating arbitrations for services rendered by non-MBB providers, including providers that were expressly ineligible to participate in arbitrations.
Aetna sought to have the IDR awards vacated and to recover damages from the fees associated with having to participate in the IDR process, and to further limit disputed claims not yet filed with the IDR. The IDR process can be costly.
The No Surprises Act and its IDR process created opportunities for insurance companies and third parties to make money at the expense of physicians, RP senior vice president of health policy Rich Heller, MD, explained for Keeping Up with the Radiologists, a podcast on the AuntMinnie Podcast Network.
"The fees to process the claim were more than the actual care delivery itself," Heller noted then, adding that third-party companies help insurance companies drive physician payment rates down.
In a single example highlighted in the April 16 court filing, Aetna was ordered by the IDR arbitrator to pay MBB an out-of-network amount of $752, instead of the in-network fee of $78.89.
RP's strongest defense was that the fraud was discoverable upon the exercise of due diligence prior to or during arbitration, Davis wrote. Furthermore, allowing Aetna to recover for the IDR awards above what it otherwise would have paid would have the same effect as discarding the administrative process established by Congress, Davis added.
In a statement via email to AuntMinnie, Radiology Partners said it was pleased with the decision.
"The ruling makes clear that this lawsuit could not be used to unwind IDR outcomes after the fact, particularly where those objections could have been raised through the process itself," stated Malea Reising, Radiology Partners' vice president of strategic communications, health policy and advocacy.
"More broadly, this case reflects a troubling pattern in which payors, dissatisfied with IDR results, increasingly try to attack those outcomes outside the framework Congress created rather than address the underlying payment issues driving the disputes," Reising added. "It would be better for all parties, especially patients and their employers, if payors focused on good-faith negotiations towards sustainable, in-network contracts."
