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January 5, 2021
On Monday in the Eastern District of New York, Judge Denis R. Hurley granted in part and denied in part a motion by Aetna Health Inc. and Aetna Health Insurance Company to dismiss allegations by Neurological Surgery PC (NSPC) that Aetna underpaid or denied full payment on 200 claims for medical services to Aetna health plan beneficiaries.
The plaintiff, “the largest private neurosurgery practice on Long Island and in the New York tri-state area,” is “out-of-network” with Aetna, which means that when Aetna plan members receive medical services from NSPC, Aetna bills the plaintiff “usual, customary, and reasonable charges for the services rendered, less any co-payment, co-insurance, member out-of-pocket, or deductible amounts,” according to the Aug. 30, 2019 complaint. Aetna members may still be treated at NSPC and sometimes are eligible for claim coverage despite being out of network. NSPC argued in its complaint that “Aetna has failed to properly and timely honor its obligation to pay NSPC for medically necessary services that NSPC provided to the members and/or subscribers of Aetna’s health plans and their beneficiaries.” On Dec. 6, 2019, the defendants moved to dismiss the complaint.