Enforcement Trends: Private Insurers Are Cracking Down on the Labs that Scam Them

Once the almost exclusive domain of federal law enforcers and inside whistleblowers, the lucrative industry of going after labs for improper billing has opened to a wide range of players encompassing just about everyone from shareholders to consumers. But of all these new private sector nemeses, none is more formidable than the insurance company. And among the insurance companies trying to force labs to cough up their ill-gotten gains, none has been more aggressive than UnitedHealthcare.

Don’t Mess With UnitedHealthcare
A pair of Texas labs are learning this lesson the hard way. UnitedHealthcare is suing Sun Clinical Laboratories and Mission Toxicology (and their owners) for allegedly “conning” it into paying $44 million worth of bogus toxicology and allergy lab testing claims. Paying physicians kickbacks for referrals is just the tip of the iceberg. The insurance giant is claiming that the labs, who are not part of its network, set up testing centers inside in-network rural hospitals to make it look like the bills came from the hospitals. Then when the United payments came in, the labs allegedly had hospital employees transfer 95% of the money to the labs and their owners. Hiding behind the hospital’s persona, the suit charges that the two labs inflated claims to 50 times the actual cost of testing, charged for tests not performed or ordered and billed for tests already billed by another provider.

The Next Health Case
Aggressive legal action against labs that “con” them is hardly a new policy for UnitedHealthcare. Last January, the insurer filed a massive lawsuit against Next Health LLC claiming that the Dallas-based provider and its subsidiaries scammed it for over $100 million in drug and genetic tests. The allegations sound like they came right out of the DOJ’s own script:

• Improper utilization of standing orders for tests administered to patients regardless of actual medical history or conditions;
• Payment of kickbacks to physicians in exchange for referrals;
• Illegal recruitment of insured patients to participate in “wellness studies” in exchange for $50 gift cards;
• Billing for tests that were never actually ordered or performed.

Other Insurers Join the Fray
Of course, UnitedHealthcare is not the only private insurer to take on labs for improper billing. Last fall, Aetna filed suits against the same two Texas labs that UnitedHealthcare is suing, i.e., Sun Clinical Laboratories and Mission Toxicology, for an alleged fraudulent billing scheme costing Aetna $21 million.

Those same two labs are also at the center of a lawsuit by Blue Cross & Blue Shield of Mississippi. The accusations in both cases follow the same pattern as the alleged violations against UnitedHealthcare–payment of kickbacks and misrepresenting claims as coming from an in-network hospital.