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California jury awards Aetna $37.4M in ASC billing fraud scheme: 6 key notes

California jury awards Aetna $37.4M in ASC billing fraud scheme: 6 key notes

A California jury ruled in favor of Aetna in a medical billing fraud case involving ambulatory surgery centers in Northern California, according to a Law 360 report.

Here are six things to know:

1. The jury found Bay Area Surgical Management and its three co-founders overbilled Aetna for out-of-network procedures by giving referring physicians a substantial kickback. The lawsuit included 10 defendants.

2. The jury awarded Aetna $37.4 million in damages after four years of litigation and a month-long trial. Aetna claimed Bay Area Surgical Management cost the insurer $23 million for around 1,900 procedures in the past two years — $20 million more than it should have been charged, according to a Mercury News report.

3. Aetna claimed Bay Area Surgical Management recruited physicians to invest in their outpatient facilities and then referred patients to those facilities. The outpatient centers charged “exorbitant” prices in out-of-network contracts, according to the Mercury News report.

4. Bay Area Surgical Management also failed to disclose the physicians’ financial interest in the referral base, which led to Aetna’s fraud claim. The surgical management company allegedly charged more than seven-times what other clinics charged for the same procedure.

5. There were around 60 Bay Area physicians investing in Bay Area Surgical Management facilities, but the physicians weren’t named in the suit.

6. United Healthcare Services also filed suit against Bay Area Surgical Management in 2012 with similar claims, according to a separate Mercury News report.


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