Judge rules in favor of orthopedic surgeon in $209K Aetna reimbursement case: 5 things to know

Written by Mackenzie Garrity | October 16, 2018 | Print  |

A New Jersey judge refused to dismiss a lawsuit between an orthopedic surgeon and Aetna for the insurer's failure to reimburse the surgeon $209,000, according to Law 360.

Here are five things to know:

1. Aetna sought to dismiss the case, siting the federal Employee Retirement Income Security Act. However, the judge ruled the state law claims involved in the lawsuit weren't preempted by any ERISA plan.

2. U.S. District Judge Anne Thompson decided in favor of Cary Glastein, MD, stating the orthopedic surgeon's claims didn't require inquiry into the patient's ERISA plan.

3. Dr. Glastein performed medically necessary surgeon in October 2016. Because Dr. Glastein was not in-network with Aetna, the orthopedic surgeon contacted the insurer prior to the surgery. Aetna sent him a written authorization for the procedure.

4. Dr. Glastein then billed Aetna $209,000, which represented "normal and reasonable charges given the complexity of the procedure and plaintiff's qualification," according to Law 360. However, he never received reimbursement.

5. The judge's decision goes against several other New Jersey federal court cases involving surgeons and out-of-network providers. In previous cases, judges have ruled the claims were preempted by ERISA.

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