45 Cal.App.5th 953
Cal. Ct. App.2020Background
- Patient S.H. presented to a hospital emergency room on April 10, 2017 with severe back pain; Dr. Adebukola Onibokun (owner of San Jose Neurospine, "SJN") performed a same-day two-level lumbar microdiscectomy.
- S.H. was insured under a KPMG group plan administered by Aetna; the plan covers emergency services under Knox‑Keene (§1371.4).
- SJN submitted claims to Aetna; Aetna paid only for non‑emergency surgery (processed out‑of‑network at 180% of Medicare) and applied payment to the member’s deductible.
- SJN rebilled and submitted an appeal identifying the services as "ER"/emergency; Aetna still denied emergency reimbursement and SJN sued alleging violation of §1371.4 and breach of an implied contract.
- The trial court granted Aetna summary judgment, reasoning incorrect CPT/service coding bars recovery; SJN appealed.
- The Court of Appeal reversed and remanded, holding triable issues exist whether the services were emergency services and whether Aetna had notice such that denial on coding grounds was improper.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| 1. Entitlement to reimbursement for emergency services under §1371.4 | SJN: services were emergency; billed/rebilled indicating "ER"; therefore plan must reimburse | Aetna: submitted CPT codes reflect non‑emergency; it processed and paid as non‑emergency | Reversed summary judgment — triable fact whether services were emergency and entitled to reimbursement |
| 2. Effect of incorrect CPT/service coding on recovery | SJN: coding mistakes do not automatically bar recovery if emergency services were actually provided or plan had notice | Aetna: wrong codes (per YDM) mean no emergency‑service reimbursement as a matter of law | Court: coding error alone is not dispositive; if plan knew or was on notice of emergency care, denial may be improper; triable issues exist |
| 3. Whether "ER" on corrected claim and Aetna testimony put Aetna on notice | SJN: corrected claim showed "ER" and Aetna employee testified provider resubmitted to identify it as emergency | Aetna: claim was already processed; disputed coding/authorization references mean it reasonably treated claim as non‑emergency | Court: reasonable jury could infer "ER" meant emergency and Aetna was on notice; summary judgment improper |
| 4. Admissibility/exclusion of opposing affidavits and declarations | SJN: trial court improperly sustained many Aetna objections and excluded admissible evidence (declarations, deposition excerpts, appeal letter) | Aetna: objections justified to exclude hearsay/unauthenticated materials | Court: many objections lacked valid grounds; trial court erred in excluding evidence; evidence supports triable issues |
Key Cases Cited
- YDM Management Co., Inc. v. Sharp Community Medical Group, Inc., 16 Cal.App.5th 613 (discusses emergency‑service reimbursement and role of CPT codes in dispute)
- Prospect Medical Group, Inc. v. Northridge Emergency Medical Group, 45 Cal.4th 497 (health plans may deny payment only if they reasonably determine services were never performed)
- Bell v. Blue Cross of California, 131 Cal.App.4th 211 (provider may recover reasonable value of emergency services when plan improperly denies claim)
- Collin v. CalPortland Co., 228 Cal.App.4th 582 (summary judgment standard and defendant’s burden to negate an element)
- Reid v. Google, Inc., 50 Cal.4th 512 (resolving doubts against party moving for summary judgment)