A White Plains optometrist is suing Aetna Inc. for $7 million for allegedly trying to claw back $7.7 million in health care payments and withholding $1 million for new claims for treatment of dry eye syndrome.
Eric C. Rubinfeld claims that Aetna is violating his health care provider agreement, in a complaint filed on Aug. 6 in Westchester Supreme Court.
Aetna’s actions are “arbitrary and groundless,” the complaint states, and interfere with Rubinfeld’s “independent medical judgment in the care and treatment of his patients.”
Rubinfeld has practiced optometry for 37 years. He has offices in White Plains, Greenburgh and Yonkers doing business as Westchester Eyes.
Since 2017, according to the complaint, he has been part of the Aetna Vision Network health maintenance program, through EyeMed Vision Care.
He treats many patients for dry eye syndrome, a degenerative disease that damages the cornea. In many instances, the patients were provided with suture-less membrane graft replacements.
Aetna routinely reimbursed the services from March 2021 through February 2024, Â the complaint states, and did not question or deny any claims on the basis of medical necessity.
But in September 2023, Aetna began a retroactive review of his services. This past February it demanded more information, and since Feb. 24, about 536 claims have been denied.
On May 7, the complaint states, Aetna notified Rubinfeld that $13.8 million in claims for suture-less membrane grafts over the previous three years were not medically necessary. It demanded that he repay $7.7 million in claims payments.
Aetna did not specify how it arrived at its conclusion, according to the complaint, and did not say that Rubinfeld had acted fraudulently or had harmed patients.
Aetna also removed two of Rubinfeld’s three offices on its website of health care providers, the complaint states, in effect terminating his service agreement. He depicts the action as retaliation for his unwillingness to repay $7.7 million.
Rubinfeld is asking the court to reinstate his service agreement with Aetna, and to award $7 million in damages.
Aetna spokesman Alex Kepnes said “we have no comment for this story.”
