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Aetna Out-of-Network Underpayments Suit Removed to Federal Court - Law Street Media

On Wednesday a case, filed by Advanced Orthopedics Hand Surgery Institute (AOHSI) against Aetna and its affiliates, was removed from the Superior Court of New Jersey Law Division Bergen County to the District of New Jersey. The case regards the underpayment of claims due to the out-of-network status of the surgeons with Aetna Insurance.

According to the filing, AOHSI performed a complicated surgical procedure on an insured patient of Aetna. Reportedly, this procedure included a left distal humerus open reduction internal fixation with olecranon osteotomy; left elbow ulnar nerve transposition; and use and interpretation of intraoperative fluoroscopy. Prior to performing this procedure, the plaintiff sought authorization from Aetna, which confirmed the medical necessity of the procedure and Aetna’s willingness to pay for the plaintiff to perform the procedure. AOHSI alleged that nowhere during the authorization procedure did Aetna indicate that it was not going to pay the “fair and reasonable” charges for the procedure. The plaintiff noted that Aetna did process and pay the bill in the amount of $960.33 out of the $143,009.67 billed amount.

AOHSI is suing for breach of contract as represented by the authorization code, promissory estoppel, and account stated. The plaintiff is represented by Lawall Mitchell, LLC. Aetna is represented by Fox Rothschild LLP.