AETNA, INC. v. OPEN MRI AND IMAGING OF ROCHELLE PARK, P.A

CourtDistrict Court, D. New Jersey
DecidedNovember 23, 2022
Docket2:21-cv-20043
StatusUnknown

This text of AETNA, INC. v. OPEN MRI AND IMAGING OF ROCHELLE PARK, P.A (AETNA, INC. v. OPEN MRI AND IMAGING OF ROCHELLE PARK, P.A) is published on Counsel Stack Legal Research, covering District Court, D. New Jersey primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
AETNA, INC. v. OPEN MRI AND IMAGING OF ROCHELLE PARK, P.A, (D.N.J. 2022).

Opinion

NOT FOR PUBLICATION UNITED STATES DISTRICT COURT DISTRICT OF NEW JERSEY AETNA, INC. et al., Civil Action No.: 21-20043

Plaintiffs,

v. OPINION OPEN MRI AND IMAGING OF ROCHELLE PARK, P.A. et al., Defendants. CECCHI, District Judge. This matter comes before the Court by way of defendants Stephen J. Conte, D.O. (“Dr. Conte”), Eugene DeSimone, M.D. (“Dr. DeSimone,” or, together with Dr. Conte, the “Doctor Defendants”), Open MRI and Imaging of Rochelle Park, P.A. (“Open MRI”), St. Irene Realty Corp. (“St. Irene Realty Corp.”), Universal Wellness Medical, Inc. (“Universal”), and Vestibula Diagnostics, P.A. doing business as Vestibular Diagnostics, P.A.’s (“Vestibula”) (collectively, the “Defendants”)1 motion to dismiss (ECF No. 36) plaintiffs Aetna, Inc. and Aetna Life Insurance Company’s (collectively, the “Plaintiffs”) Complaint (ECF No. 1) pursuant to Federal Rule of Civil Procedure 12(b)(6).2 Plaintiffs filed an opposition, and cross-moved for partial judgment on the pleadings pursuant to Federal Rule of Civil Procedure 12(c). ECF No. 45. Defendants did not reply. The Court decides this matter without oral argument pursuant to Federal Rule of Civil

1 Defendants Salvatore Conte, M.D. (“Dr. Salvatore Conte”), Raymond Reiter, M.D., Doney Jain, M.D., George Hermann, M.D., and Integrated Wellness Medicine, LLC (“Integrated”) did not join the instant motion. Colin A. Pemberton, M.D. has been dismissed from this action. 2 The Court notes that Defendants have characterized their motion as a “motion to dismiss counterclaims.” ECF No. 36. However, as no counterclaims have been filed, the Court construes the motion as a motion to dismiss Plaintiffs’ Complaint. See EMC Outdoor, LLC v. Stuart, No. 17- cv-5172, 2018 WL 3208155, at *1 (E.D. Pa. June 28, 2018) (“For the purposes of a Rule 12(b)(6) motion to dismiss, claims and counterclaims are treated equivalently, and the standards of review are the same.” (internal quotations and citation omitted)). Procedure 78. For the reasons set forth below, both Defendants’ motion to dismiss and Plaintiffs’ cross-motion for partial judgment on the pleadings are denied. I. BACKGROUND3 This case arises out of allegations that Defendants engaged in fraudulent billing schemes to profit from administering to patients COVID-19 rapid tests.

A. Parties Dr. Conte is a Doctor of Osteopathic Medicine, who practiced at Open MRI, Vestibula, and Universal. ECF No. 1 at ¶ 16. Open MRI and Vestibula are New Jersey professional associations and Universal is a New Jersey Corporation, all with the same principal place of business at 251 Rochelle Avenue, Rochelle Park, New Jersey. Id. at ¶¶ 13–15. Dr. Conte is the registered agent and president of Open MRI, the registered agent and founder of Vestibula, and principal and member of Universal’s board of directors. Id. Corporate documents name Dr. Conte as an owner of these three entities. Id. at ¶ 16. In addition to his association with these entities, during the relevant period, Dr. Conte

owned, operated, and served as the registered agent for St. Irene Realty, a New Jersey corporation with the same principal place of business address as Dr. Conte’s home address in Paramus, New Jersey. Id. at ¶¶ 25–26. St. Irene Realty is the owner of 251 Rochelle Avenue, Rochelle Park, New Jersey, the business address for Open MRI, Vestibula, and Universal. Id. at ¶ 26. Among other Defendants relevant to the instant motion, Dr. DeSimone rendered medical services at Vestibula and Universal. Id. at ¶ 17. Moreover, Dr. Salvatore Conte provided medical services at Vestibula, Universal, and Integrated Wellness, a New Jersey limited liability company formed by Dr. Salvatore Conte in 2020. Id. at ¶¶ 18, 23.

3 The following facts are accepted as true for the purposes of the motion to dismiss. B. General Practices Plaintiffs allege that at the outset of the COVID-19 pandemic, Open MRI and Vestibula, radiology laboratories, began providing COVID-19 rapid tests to patients at their joint practice location at 251 Rochelle Avenue, Rochelle Park, New Jersey. Id. at ¶ 44. Plaintiffs assert that in taking a rapid test at Open MRI or Vestibula, a patient “would have their temperature taken, answer

a series of screening questions regarding their symptoms, receive a nasal swab, and shortly thereafter be provided with test results. Id. at ¶ 45. Plaintiffs contend that the entire interaction would last “no more than a few minutes and involved minimal interaction with a physician.” Id. at ¶ 46. Defendants allegedly charged their patients $35 for a rapid test, but then “submitted significantly higher charges” to Plaintiffs for reimbursement. Id. at ¶ 47. In general, to be compensated by insurers like Plaintiffs for services such as administering a COVID-19 rapid test, healthcare providers like Defendants submit to insurers claims via standardized billing forms that use “numerical codes that describes the services for which the providers seek payment.” Id. at ¶ 34. Plaintiff alleges it relies upon healthcare providers to

accurately describe the services they render so payment can be appropriately disbursed. Id. at ¶ 35. And moreover, Plaintiffs contend that claims must “be certified as correct and complete and that the benefits being claimed be limited to charges actually incurred.” Id. at ¶ 37 (citing ECF No. 1- 3). Plaintiffs also assert that any provider submitting claims is required to be “appropriately licensed and credentialed to legally render, and personally render, the services being billed.” Id. at ¶ 38. Plaintiffs allege that to profit from the administration of COVID-19 rapid tests Defendants implemented four fraudulent schemes: 1) billing for COVID-19 tests performed without required licenses and authorizations; 2) billing for specimen handling services not rendered; 3) inflating charges for services provided, a tactic known as “upcoding”; and 4) submitting claims through various businesses to avoid Plaintiff’s fraud detection protocols. i. Licensing Plaintiffs allege that Defendants submitted claims to Plaintiff for administering COVID-

19 rapid tests, representing that Defendants were properly certified and licensed to provide such tests to their patients. Id. at ¶ 56. However, Plaintiffs assert that from April 2020 through at least September 22, 2020 Vestibula was not credentialed pursuant to the Clinical Laboratory Improvement Act of 1988, and thus was not authorized to administer COVID-19 tests. Id. at ¶ 57 (citing ECF No. 1-5). Similarly, Universal was purportedly unlicensed and unauthorized to provide COVID-19 tests from July 2020 through at least November 8, 2020. Id. at ¶ 61 (citing ECF No. 1- 8). Moreover, Plaintiffs allege that Open MRI was at no times authorized to conduct COVID-19 testing and related services. Id. at ¶ 59. Plaintiffs assert that while these entities were without proper licensing, they nevertheless administered COVID-19 tests and improperly submitted claims

to Plaintiffs to recover payment for this service. Specifically, Plaintiffs contend that Vestibula billed Plaintiffs $65,000 (id. at ¶ 58 (citing ECF No. 1-6)), Open MRI billed Plaintiffs over $6,000 (id. at ¶ 60 (citing ECF No. 1-7)), and Universal billed Plaintiffs at least once for administering COVID-19 rapid tests (id. at ¶ 62 (ECF No. 1-9)). ii. Billing for Specimen Handling Plaintiffs further assert that, in all of their claims for COVID-19 rapid testing, Defendants also billed Plaintiffs for “specimen handling,” which “involves the handling of test samples for transfer to a laboratory.” Id. at ¶¶ 65–66. However, according to Plaintiffs, rapid COVID-19 tests do not require specimen handling because rapid tests are processed in the location at which they

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Ashcroft v. Iqbal
556 U.S. 662 (Supreme Court, 2009)
Phillips v. County of Allegheny
515 F.3d 224 (Third Circuit, 2008)
Frederico v. Home Depot
507 F.3d 188 (Third Circuit, 2007)
MK STRATEGIES, LLC v. Ann Taylor Stores Corp.
567 F. Supp. 2d 729 (D. New Jersey, 2008)
Kaufman v. I-Stat Corp.
754 A.2d 1188 (Supreme Court of New Jersey, 2000)
State, Dept. of Treasury v. Qwest Communications International, Inc.
904 A.2d 775 (New Jersey Superior Court App Division, 2006)
Gennari v. Weichert Co. Realtors
691 A.2d 350 (Supreme Court of New Jersey, 1997)
Thomas Foglia v. Renal Ventures Management
754 F.3d 153 (Third Circuit, 2014)
Travelers Indemnity Co. v. Cephalon, Inc.
620 F. App'x 82 (Third Circuit, 2015)
Kuzian v. Electrolux Home Products, Inc.
937 F. Supp. 2d 599 (D. New Jersey, 2013)
Stockroom, Inc. v. Dydacomp Development Corp.
941 F. Supp. 2d 537 (D. New Jersey, 2013)

Cite This Page — Counsel Stack

Bluebook (online)
AETNA, INC. v. OPEN MRI AND IMAGING OF ROCHELLE PARK, P.A, Counsel Stack Legal Research, https://law.counselstack.com/opinion/aetna-inc-v-open-mri-and-imaging-of-rochelle-park-pa-njd-2022.