Aetna illegally refused to pay $75,200 for emergency spine procedure, practice alleges

Written by Angie Stewart | March 02, 2020 | Print  |

San Jose Neurospine is battling Aetna Health California in court, alleging that the insurer illegally refused to pay for emergency medical services performed by spine surgeon Adebukola Onibokun, MD, the practice's owner.

What you should know:

1. The case centers on a two-level lumbar microdiscectomy that Dr. Onibokun performed in April 2017. San Jose Neurospine submitted two claims to Aetna for reimbursement — one for emergency medical services and one for nonemergency surgery. Aetna only provided payment for the latter.

2. San Jose Neurospine filed a civil action against Aetna two months after appealing Aetna's denial. The practice alleged that Aetna owed $75,200 for emergency medical services covered under the patient's healthcare plan.

3. Aetna filed a motion for a summary judgment, claiming that San Jose Neurospine used incorrect codes and therefore wasn't entitled to payment for emergency services. Aetna was granted the summary judgment, meaning it showed that one or more elements of the plaintiff's case were missing or that it was entirely defensible, rendering a trial unnecessary.

4. San Jose Neurospine appealed the ruling. On Feb. 27, the California Court of Appeal in the Second District concluded "there are triable issues of fact whether SJN provided and billed for emergency services and was entitled to reimbursement from Aetna." The court reversed the summary judgment and remanded the case for further proceedings.

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