By Carole C. Schriefer, R.N., J.D., The Health Law Firm
On July 14, 2016, a Colorado federal judge partly dismissed allegations against several surgical centers in claims filed by insurance companies Aetna and UnitedHealthcare. The judge disagreed that the two surgical centers committed fraud by waiving patient fees or violated antitrust laws by sending hefty bills to the insurers.
The dismissals applied to counterclaims filed by Aetna and UnitedHealthcare against four out-of-network surgical centers that are suing the insurers for allegedly blocking patient referrals. Although the centers accuse Aetna and UnitedHealthcare of anti-competitive efforts to destroy the centers’ business model, the insurers allege that the business model — which involves waiving patient fees and recruiting patients from in-network doctors — is itself illegal.
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The Dismissed Allegations.
U.S. District Judge William J. Martinez, dismissed allegations of fraud and negligent misrepresentation against the two insurance centers. He did so after finding that the billing claims submitted to both Aetna and UnitedHealthcare disclosed “that the patient’s responsibility has been reduced to approximate in-network rates,” and that the insurers were therefore not deceived.
Additionally, the judge also dismissed counterclaims brought under state and federal antitrust laws. Those counterclaims were announced on an alleged price-fixing conspiracy among the insurance centers to bill insurers at 800 percent of Medicare reimbursement rates. Judge Martinez found that the two insurers had no obligation to pay the inflated rates and therefore were not harmed.
“To the extent [Aetna and UnitedHealthcare] paid a reimbursement that was artificially inflated by a price-fixing conspiracy, the injury was self-inflicted,” the judge wrote. “The court is unwilling to hold that paying an illegally inflated price constitutes antitrust injury when the paying party disregards its right to pay less or nothing at all.”
Counterclaims and Violations.
Judge Martinez also threw out several other counterclaims brought under other various theories and laws, including the Colorado Consumer Protection Act.
But he refused to dismiss counterclaims alleging tortious interference, unjust enrichment, civil conspiracy and violations of the Employee Retirement Income Security Act.
The judge said that the tortious interference counterclaim is potentially viable because both Aetna and UnitedHealthcare sufficiently alleged that inducing patients to “shirk their out-of-network cost-sharing” would violate Colorado’s abuse-of-health insurance statute.
To read Judge Martinez’s order in full, click here.
The case is Kissing Camels Surgery Center LLC et al. v. Centura Health Corp. et al.
Contact Health Law Attorneys Experienced With Healthcare Business Practices.
The Health Law Firm routinely represents physician groups and practices with issues involving establishing, licensing, selling, merging, and intergroup affiliation. If you are considering establishing an ACO or have been approached to become a participant in one, you can contact The Health Law Firm at (970) 416-7456 or (407) 331-6620 or (850) 439-1001 or you can visit our website at www.TheHealthLawFirm.com.
Overley, Jeff. “Aetna, Anthem, United Can’t Ax Referral-Blocking Claims.” Law360. (July 17, 2016). Web.
About the Author: Carole C. Schriefer is an attorney and registered nurse. She practices with The Health Law Firm, which has a national practice. Its regional office is in the Northern Colorado, area. www.TheHealthLawFirm.com The Health Law Firm, 155 East Boardwalk Drive, Fort Collins, Colorado 80525. Phone: (970) 416-7456. Its main office is in the Orlando, Florida area.
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