PHILADELPHIA – Aetna is suing both a clinical laboratory and sales company it says led the company to pay out numerous fraudulent health insurance claims and is seeking to recover “tens of millions” in monetary damages in the process.
Aetna filed suit on April 10 against Health Diagnostic Laboratory and Bluewave Healthcare Consultants, alleging fraud, tortious interference, civil conspiracy and unjust enrichment.
According to the lawsuit, Aetna claims HDL and Bluewave conspired to defraud it of millions of dollars through “a fraudulent billing scheme that included paying illegal kickbacks to physicians, providing unlawful inducements to patients, and encouraging physicians to order unnecessary blood tests, resulting in fraudulent and inflated medical claims being submitted to Aetna for reimbursement.”
The lawsuit further alleges “illegal kickbacks and inducements were used by defendants to induce physicians and patients to utilize HDL for blood sample testing, rather than to use less expensive but equally qualified laboratories. Illegal kickbacks and inducements were also used to cause unnecessary blood tests to be ordered from HDL.”
Typically, Aetna claims its customers would use a medical provider who had contracted with Aetna for its services, known as a “participating” or “in-network” provider, in order to benefit from a lower co-payment amount and minimize health care costs.
For occasions when customers use other medical providers not contracted to Aetna, known as “out-of-network” providers, the co-payment amount is generally far higher for customers than if they selected an in-network provider. The lawsuit claims HDL was an out-of-network provider, with no affiliation to Aetna.
Aetna claims that Bluewave contacted many physicians throughout the United States, offering to financially compensate them with kickbacks for referring patients requiring blood sample testing to HDL, business which HDL would not ordinarily receive.
“In their kickback scheme, HDL and Bluewave nevertheless assured physicians that they would receive payment of a fee of $20 for each blood specimen sent to HDL. This is more than six times the rate deemed permissible by Medicare,” the lawsuit says.
According to federal guidelines, Medicare allows laboratories to compensate a physician’s office about $3 for such services, Aetna says.
The suit claims HDL billed Aetna, well aware its status as an out-of-network provider would ensure it receiving a far higher percentage of the cost of its services from Aetna than would an Aetna-affiliated, in-network provider.
Aetna stated in its suit that HDL routinely waived the co-payment costs incurred by patients for its services as an out-of-network provider, a factor which HDL allegedly did not account for when later billing Aetna.
The plaintiff alleges these deceptive practices caused Aetna to pay HDL millions in fraudulent and inflated medical claims, with Bluewave receiving a share of the supposedly ill-gotten gains in the form of “commissions.”
According to the lawsuit, Aetna is seeking well in excess of $150,000, plus punitive damages and court costs.
Aetna is a Pennsylvania corporation headquartered in Stamford, Conn., that conducts “substantial” business operations in Blue Bell.
HDL is based in Virginia and was founded in 2008 by Tonya Mallory, who served as President and CEO of HDL until her resignation last September. The lawsuit alleges convenient timing regarding Mallory’s resignation, in that it came shortly after it was publicly reported that a federal investigation into HDL’s business practices had been launched.
Bluewave is based in Alabama, having been founded by Cal Dent and Brad Johnson in 2010. During the time period of the fraudulent activity alleged in Aetna’s lawsuit, Dent and Johnson were also part-owners of HDL.
The lawsuit also notes that Mallory, Dent and Johnson were all previously employed by Berkeley Heartlab, Inc., another diagnostic lab facility which analyzes blood sample specimens for medical testing, before leaving to form their respective companies.
The plaintiff is represented by John M. Elliott of Blue Bell-based firm Elliott Greenleaf & Siedzikowski, P.C.
United States District Court for the Eastern District of Pennsylvania case 2:15-cv-01868