Aetna’s “Fraud Scheme” Lawsuit Against Radiology Group Highlights Health Plans’ Resistance to Private-Equity-Backed Providers

On December 23, 2024, various Aetna affiliates (referred to hereafter as Aetna) filed suit against Radiology Partners, Inc., a national, private-equity-backed radiology group, alleging that Radiology Partners defrauded the insurer and its plan sponsors out of “tens of millions of dollars through fraudulent medical claims.” According to Aetna’s complaint, Radiology Partners was formed in 2012 and has since acquired or been affiliated with at least nine radiology practices in Florida, including Mori, Bean and Brooks, Inc. (MBB). Each practice maintains a separate tax identification number (TIN) and separate provider contracts with Aetna.

Aetna’s complaint alleges that in “phase one of the scheme,” Radiology Partners began billing for all services performed by all Radiology Partners-affiliated Florida practices under MBB’s Aetna contract, which had the most favorable reimbursement rates. The complaint alleges that the number of physicians billing under MBB’s TIN has increased from about 50 at the time of the Radiology Partners acquisition in September 2018 to more than 1,000 since. In response to MBB’s increase in claim volume, Aetna terminated MBB’s in-network contract.

Following the termination, Radiology Partners pivoted to what Aetna characterizes as the “second phase,” under which Radiology Partners continued to bill all of its Florida radiology services through MBB on an out-of-network basis. Because of MBB’s status as an out-of-network provider, its claims were subject to the No Surprises Act (NSA). The NSA, which took effect in 2022, limits patients’ costs for out-of-network services and established an independent dispute resolution (IDR) process to resolve payment disputes between providers and health plans. Per the complaint, Radiology Partners has initiated “tens of thousands” of arbitration proceedings under IDR and is responsible for more than 90% of all NSA IDR cases involving claims for professional radiology services.

Aetna claims Radiology Partners billed more than 110,000 claims under MBB’s TIN, causing MBB to receive more than $20 million, to which it was not entitled. The complaint seeks monetary damages and injunctive relief pursuant to 11 claims, including claims of fraud and tortious interference with contract.

Aetna’s lawsuit comes just months after the resolution of UnitedHealthcare’s (UHC’s) 2023 lawsuit against Radiology Partners alleging a similar “pass-through billing scheme” employed in Texas. The UHC lawsuit was resolved via arbitration in September 2024. In that case, UHC charged that Radiology Partners billed for services performed by its network of more than 3,000 physicians under a lucrative contract held by a single affiliated practice, Singleton Associates, PA.

Both Aetna’s and UHC’s complaints specifically highlight and criticize private equity’s role in providers’ alleged misconduct. In its complaint, Aetna likens Radiology Partners’ alleged scheme to the Federal Trade Commission’s recent action against US Anesthesia Partners, another private-equity-backed provider. Aetna claims that both provider groups sought to consolidate practices in fragmented markets and engaged in billing schemes with “disastrous effects.” Aetna alleges that such conduct cost individuals “exponentially more” with “no increased value in care or services.”

Accordingly, Aetna’s complaint exemplifies a trend toward health plans attributing alleged billing misconduct to the role of private equity. While the outcome of the suit remains to be determined, private equity sponsors should be aware of this environment and the potential for increased scrutiny of their affiliated providers.

A copy of the complaint can be found here.

 

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