LOS ANGELES – A state appeals panel determined a coding error shouldn’t prevent proper reimbursement for medical services.
A three-justice panel of the California 2nd Appellate District, Division Six said Ventura County Superior Court Judge Henry Walsh wrongly settled a dispute between San Jose Neurospine and Aetna Health of California and others. Presiding Justice Arthur Gilbert wrote the opinion; Justices Steven Perren and Martin Tangeman concurred.
The underlying issue is emergency lumbar disc surgery SJN owner Dr. Adebukola Onibokun performed in April 2017 for someone covered under their employer’s Aetna group policy. After Aetna granted two claims only for non-emergency surgery and denied an appeal, SJN filed a seven-count lawsuit alleging Aetna was obligated to pay $75,200 for its client’s operation.
Walsh granted summary judgment, agreeing with Aetna’s position it complied with the initial health insurance claim form using current procedural terminology codes for non-emergency surgery. SJN countered by claiming it sent a second bill stipulating the emergency nature of the operation.
“It has been said the law is based on technicalities,” Gilbert wrote. “But technicalities that ignore legislation, common sense and fairness, the law abhors.”
While acknowledging it might’ve initially used incorrect CPT numbers, SJN said a judge or jury “could reasonably infer Aetna was on notice these services were emergency service claims that should have been granted,” Gilbert wrote, adding the corrected billing form used the term “ER” three times.
Walsh said there was nothing showing what “ER” means, though Gilbert wrote that there is a “reasonable, well-understood” definition as well as “triable issues concerning what a medical insurance company should know and do when it sees such an ‘ER reference.'”
The panel also pointed to deposition testimony from an Aetna employee who acknowledged SJN’s claims indicated an emergency operation, along with testimony from the patient and Onibokun detailing the emergency nature of the condition.
California law, according to the panel, requires insurance plans to include a mechanism for resolving disputes, indicating lawmakers didn’t intend for a system wherein a company like Aetna could end responsibility for paying based on a mistake on an initial claim form. Further, the law expressly stipulates when an insurer is allowed to deny payment for emergency services, conditions the panel said Aetna didn’t meet in this instance.
The panel reversed Walsh’s judgment and remanded the case for further proceedings.
SJN is represented in the matter by Nordic Star and Nicholas Van Parys.
Representing Aetna are Raines Feldman, LLP, and Richard Decker, Marc Berkemeier and Robert Shore.