Insurance Business reports that Allstate has sued Florida Orthopedics and Neurosurgery, which does business as University Orthopedic Care, along with its two owners, “under federal racketeering law, accusing it of running a kickback-driven billing scheme that cost the insurer millions.”
In the complaint filed in U.S. District Court for the Middle District of Florida, Allstate accuses the practice of employing a “predetermined treatment protocol to push patients into unnecessary injections, surgeries, drug cocktails and durable medical equipment to inflate insurance bills,” reports the magazine, which adds that Allstate is asking the court to “wipe out pending and previously denied claims from the clinic.”
Insurance Business describes the alleged scheme according to Allstate:
At the center of the complaint is a kickback structure Allstate says was built to multiply facility fees. The filing alleges that when University Orthopedic sent a patient to an ambulatory surgery center for routine pain treatment, the surgery center would bill Allstate a large facility fee - then sell the right to collect that fee to a related company, ASC Lender, LLC, for a fraction of the amount. In one example, a surgery center billed $16,500 for a radiofrequency ablation and sold the right to collect to ASC Lender for $1,500. The complaint alleges the same $16,500-for-$1,500 swap on a second patient. In another, the facility fee for a shoulder surgery was $65,020 … Allstate describes the returns on these fee purchases as “potential 1,000% returns” and casts them as a kickback meant to drive referrals and unnecessary surgery center use.
ASC Lender, Insurance Business reports, is co-owned by the clinic’s CFO and another person who has a financial interest in University Orthopedic Care. You can read much more about the suit and the allegations in Insurance Business’ full report.
Allstate appears to be sharply focused on ASC billing fraud. Last month, Insurance Business reported on its suit against Surgery Partners, anesthesia group Anesthesiology Professional Services and a group of Florida ASCs and pain management centers, which it accused of “running a multimillion-dollar billing scheme that quietly drained its auto insurance payouts.”
That suit, also filed in the U.S. District Court for the Middle District of Florida, involves patients who went to the accused facilities for treatment after car accidents. Allstate alleges that many claims involving these patients were for procedures that were “unnecessary, exaggerated, or - in some cases - never actually performed,” according to Insurance Business, which writes that Allstate alleges it paid millions of dollars on claims “based on the false, fabricated, unlawful, and improper medical services billed by the defendants.”
Insurance Business added that some of the claims in this case “read like a clinic on how to spot suspicious billing.” Read its full report on this lawsuit here.
