A Hawthorne pharmacy claims that Aetna Inc. is not covering the costs of out-of-network drugs for its health insurance members.
Superior Biologics NY Inc. sued Aetna on June 14 in Westchester Supreme Court seeking reimbursement for $3.4 million in services.
“Aetna issued blanket denials of the claims,” the complaint states, “without regard to the medical necessity of the services rendered to its members.”
Aetna media relations did not respond to an email request for comment.
Superior Biologics is a home infusion and specialty pharmacy that supplies medications for patients with acute and chronic illnesses. The company is based in Sharon Hill, Pennsylvania, near Philadelphia, and operates a regional facility from a warehouse on Saw Mill River Road in Hawthorne.
Before delivering drugs, Superior Biologics verifies with the insurer that the service is covered and, if necessary, gets a prior authorization for treatment. After the service is provided, it submits a claim to the insurer for reimbursement.
Superior Biologics does not have an in-network contract with Aetna, the complaint states, and has not agreed to accept a discounted rate for services.
But under New York law, health care insurers must pay providers reasonable value for medically necessary services, according to the complaint, defined as at least 80 percent of the usual and customary rate for the same or similar services in the same geographic area.
Aetna consistently pays for nursing and supplies, Superior Biologics claims, but generally refuses to pay for the drugs.
“Aetna has engaged in a scheme to unilaterally set its own, artificially low reimbursement rates for the health care services provided,” Superior Biologics alleges.
The pharmacy accuses Aetna of violations of an implied contract and of the New York Prompt Pay Statute, and of unjustly enriching itself by not reimbursing more than $3.4 million in services for its members.
Superior Biologics is asking the court to declare that Aetna must pay for all out-of-network claims at the usual and customary costs.
Superior Biologics is represented by Kevin G. Donoghue of Garfunkel Wild PC of Great Neck.