Judge Sides With Aetna Against Texas Clinics

Aetna is collecting $8.4 million from a small hospital and three clinics after a Texas judge ruled the facilities overbilled the insurer for two years. 

According to HealthcarePayerNews.com, a federal judge in Texas sided with Aetna in August, saying three freestanding emergency clinics north of Houston — Trinity Healthcare Network, ER DOC 24/7, and Premier Emergency Room and Imaging (which has since closed) — lied about being affiliated with Cleveland Imaging and Surgical Hospital, a nearby four-bed hospital, to charge higher fees. As a result, the clinics overbilled Aetna by $9.3 million over the course of two years, the judge says. 

HealthcarePayerNews.com reports Cleveland Imaging and Surgical Hospital let the clinics use its provider number in exchange for about 15 percent of the payments from Aetna.

"Using the hospital's number made it look like the clinics' treatment happened at a full-service hospital, rather than an unlicensed clinic," wrote U.S. District Judge Lynn Hughes. "If these clinics want to charge higher fees, they need to become a licensed hospital, not craft devious, inauthentic billing contracts to make it appear as though they have become part of the hospital."

The ruling did not address Aetna's accusations of fraud, negligent misrepresentation, and civil conspiracy on the part of the clinics. The owners of the clinics argued in court their billing was legal based on the arrangement with the licensed hospital. 

Trinity said in a statement to the Fort Worth Star-Telegram, "Aetna has decided to increase their profits on the backs of low-cost community facilities like Trinity Healthcare that is designed to decrease cost to their patients. Trinity Healthcare will be appealing this decision without hesitation." 

Action, Oct. 31, 2014

Last Updated On

April 23, 2016

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