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A Voice for Private Physicians Since 1943

Court Rules Against Aetna For Refusing to Pay for Emergency Surgery Due to CPT Coding Error

AAPS sided with a Californian physician on problems he was having as an out-of-network spine surgeon.  Insurers refused to pay him a reasonable amount for his services, despite his stellar record and how California (like many states) recognizes the right of physicians to sue insurance companies for out-of-network emergency services.  This is an essential exception to the price controls being imposed on physicians under the guise of “surprise billing” laws.

In one of his cases, Aetna refused to pay him because it said he used the wrong CPT code for emergency services, even though his billing office clarified that the surgery was done on an emergency basis after the patient went to the ER in enormous pain.  Insurance companies should not use CPT intricacies as an excuse for refusing to pay.

The physician performed emergency spine surgery on a patient from the ER who felt like she might otherwise die from the pain.  She provided a sworn statement that she had “excruciating back pain … and the inability to walk.”  The billing company indicated the surgery was performed on an emergency basis on the bills to the insurance company, Aetna.  Yet the trial judge ruled completely for Aetna, as many trial judges do for insurance companies.  It granted summary judgment based on Aetna’s argument that because an “incorrect” non-emergency CPT code was initially used, the physician had no right to payment.  But an out-of-network physician should not be obligated to use particular CPT codes to get paid by an insurance company!

Enter AAPS.  Even though appellate courts rarely reverse a decision against a physician in this type of case, we saw a way to establish a precedent to help all physicians.  So we sided with the physician on appeal.

On Feb. 27 the California appellate court held completely and unanimously in favor of our side, in a precedential decision which all physicians can use! 

“It has been said the law is based on technicalities. But technicalities that ignore legislation, common sense, and fairness, the law abhors,” stated the court in

Its wonderful decision is here, marked “CERTIFIED FOR PUBLICATION”:   https://www.courts.ca.gov/opinions/documents/B296716.PDF

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