Koeher Vs Aetna Health Care Case Summary

This firm represents North Texas Division, Inc. and its affiliated facilities, including Medical City Dallas Hospital (“Medical City”). Reference is made to the Medicare Advantage Facility Participation Agreement (eff. October 30, 2010) as amended (collectively, the “Agreement”). I write regarding SelectCare’s failure to appropriately adjudicate a claim by Medical City for services provided to patient E.F. By this letter, the Hospitals invoke all dispute resolution procedures permitted or required under the Agreement.
Patient E.F. was admitted to Medical City Dallas from August 30 through September 25, 2015. Unfortunately, the patient was mistakenly admitted by the hospital under the wrong name – i.e., the name of a patient with the same
In this case, authorization was provided for the services, although under the incorrect patient information. Considering that SelectCare was promptly notified of the mistake, and that had the correct patient information been given, authorization would have been provided for the medically necessary services for patient E.F., the purported lack of authorization does not support denial of this claim. Indeed, it was no more than a technical default that caused no prejudice to SelectCare. See Koehler v. Aetna Health Inc., 683 F.3d 182, 188 (5th Cir. 2012) (recognizing that a lack of preauthorization “does not prejudice [the insurer]’s ability to refuse coverage if it concludes that the services were not medically necessary”); Weaver v. Phoenix Home Life Mut. Ins. Co., 990 F.2d 154, 158-59 (4th Cir. 1993) (reversing plan administrator’s denial of coverage because its denial that “hospital confinement commencing 05/16/90 was not authorized” was conclusory and the medical necessity of the inpatient stay, not any authorization of it, was what determined coverage). Under these circumstances, Medical City is entitled to payment in full for its services in the amount of $74,404.44. Demand is made for payment of this