At the center of the dispute medical bill case is Dr. Robert A. Behar, identified in court records as the CEO of North Cypress. According to court documents, physicians were offered ownership interest in North Cypress in exchange for recommendations and patient referrals to North Cypress over less-expensive, in-network facilities.
In a move that takes the issue of emergency room cost and other hospital billing disputes to a new level, North Cypress is alleged to have consistently billed Aetna for procedures that were charged at a much higher cost than similar hospitals.
As an example, it is alleged that Aetna was billed for $3.1 million for surgical anchor screws at a rate exceeding $2,500 for each screw. It is alleged that North Cypress utilized non-specific billing codes. It is also alleged that North Cypress purposely provided incorrect codes for services and procedures undertaken in various sectors of the hospital - including the emergency room - resulting in significantly higher emergency room cost.
Combined, North Cypress is alleged to have increased its gross revenues by hundreds of millions of dollars above the revenues of comparable hospitals. Doctors who consistently referred patients to North Cypress are described as having the potential to become “millionaires virtually overnight” through the acquisition of an ownership stake in the hospital as incentive. Doctors failing to refer a sufficient number of patients were reprimanded and threatened, or forced to relinquish their ownership stakes in the hospital, or so it was alleged.
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“The financial harm inflicted on Aetna and the healthcare system was not by happenstance, but by pure design,” the complaint said.“Dr. Behar intended to harm Aetna as part of his greed and personal vendetta against the managed care industry and, in fact, routinely expressed his desire to bilk Aetna and other payors.”
The hospital overcharging lawsuit included claims under the Racketeer Influenced and Corrupt Organizations Act, in addition to claims for interference and breach of contract.
The case is Aetna Life Insurance Co. v. Robert A. Behar, M.D. et al, Case No. 4:15-cv-491 in the US District Court for the Southern District of Texas.