Jury awards Aetna $37.4M in fraud case

A Santa Clara, California, jury awarded Aetna $37.4 million following a month-long trial in which the insurer accused a network of surgical centers of paying kickbacks to referring physicians, waiving patient co-pays and overbilling for out-of-network procedures, according to Law360.

The case--which was originally filed in 2012--involved claims that Bay Area Surgical Management LLC and its affiliated surgical centers waived patient co-pays for patients while surgeons offered potentially lucrative ownership shares to referring physicians in order to submit exorbitant claims for out-of-network care.  Aetna's attorneys called it an "insidious scheme" in which the surgical centers billed $23 million for claims that should have cost approximately $3 million.  

The attorney for Bay Area Surgical Management, Michael Amir of Doll Amir & Eley LLP, told Law360 that the management group would appeal the decision, and argued that it was Aetna's duty to determine how much of the claims to pay, rather than paying the full amount submitted.

The legal battle was punctuated by countersuits against Aetna by hospital groups and physician coalitions and claims that the insurer was booting doctors from its network in retaliation. In 2012, Cigna also sued a New Jersey surgery center for waiving co-pays for out-of-network providers.

To learn more:
- read the Law360 article