re: Doctors win lawsuit against Blue Cross Blue Shield

As a husband whose wife went through a year and half process of chemo, radiation and multiple surgeries recently.

There is no such thing as bougie, just who will do the best job.

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This is where you would bring any woman that you loved.

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And pay the additional money that being out of network will not be covered by insurance.

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James Williams from the Board of Supervisors tried it.

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Must have had some black doctors affected or black patients the doctors were going to go after if this didn’t work out.

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Paying claims increases premiums. If insureds would just be happy, pay their insurance, and not make any damn claims, things would be just fine. /s

Brought son to emergency room last year. He stayed overnight. 25k. Because of self pay, discount down to $6700. Makes you wonder how much they are overcharging insurance companies

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First, according to the article it was 9000 procedures over 8 years that were preapproved. That would be just under $47k average per procedure not counting any interest. That would arguably be high for just physicians surgical fees but the Center for Breast Reconstruction is a stand a alone hospital that provides end to end care for at least those local or willing to travel or stay for all followups. $47k is probably at most half maybe even as low as a quarter for the total bill for bilateral reconstruction especially the more involved procedures like APEX and DIEP flap procedures. I think a lot more information is needed to determine the sanity of the verdict.

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Of note too, the center was considered out of network for Blue Cross meaning it was only obligated to pay 50-65% of costs depending on a patient’s insurance plan. Now knowing the types of patients they were seeing, some probably thought they would hit their out of pocket max for the year, but on many plans that cut off is only on in network procedures.

With that said if each procedure with follow-ups cost 50k, at a 50% out of network deductible, Blue cross was obligated to pay at least half at 25k that does mean this center would have been billing the patients another 25k. Unless the center was trying to pull the old trick of we will bill your insurance 3 times the cost, to collect a third and if we get a satisfactory amount we will cancel the rest of the bill.

Blue Cross might have been seeing this and was trying to ensure the right payments because part of the lawsuit was that Blue Cross was dragging their feet on paying claims. Blue Cross also wanted them to be an in network provider, but it looks like clinic didn’t want the scrutiny that comes from being an in network provider since that would have reduced their ability to overbill and would have set comparable contract rates like other providers in the region.

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Quick check of their website shows 8 doctors. So each doc gets $50 million? Something is fishy here

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I wouldn’t be surprised if there is a lot of interest and penalties in that number.

Also, how many years of income does that cover?


As noted below, these are complicated surgeries. If pimple poppers are making millions a year, how much should a best in class plastic surgeon who gave up a decade of his life to training make? Probably a lot.

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Honestly there’s only 4-5 surgeons in the SE Louisiana region that I would feel comfortable with for this procedure.

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I wonder if my surgeon would make your list. He and his partner managed to do it in 5 hours and I was happy with the results.

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This is one of those things that is specialized and should surgeon choice not be dictated by insurance.

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So, you think that these doctors should be able to stay out-of-network and then charge whatever the frick they want and that an insurance company should be required to pay that amount despite the fact that they have no fricking contract or agreement with that doctor?

Every insurance company I've ever dealt with have clear provisions on what they will cover for in-network providers and out-of-network providers. In the past I have chosen to go to out-of-network providers on rare occasions. And, I knew that I would be responsible for a much greater dollar amount by doing so. THAT WAS MY CHOICE.

Same here. If the patient wants to go to doctors who refuse to negotiate with their insurance company (and become in-network) then they (the patients) are on the hook for whatever their insurance is not contractually obligated to pay. In these situations, there really isn't any privity of contract between the doctors and the insurance company that they refuse to negotiate with. This really is basic contract fricking law and should never have been given to a jury to come up with this absurd number whereby, IT SEEMS, the doctors just charged whatever the frick they wanted and the jury awarded them that amount for apparently sympathetic reasons.

Since it was the patient who CHOSE to go to a doctor they KNEW was out-of-network, THE PATIENT should be required to come up with the difference between what the insurance company was contractually obligated to pay and what the doctors billed. And, like I mentioned above, the DOCTORS should be required to spell all of this out before they perform any procedure so that they patients know exactly what they are going to be on the hook for.

And, the doctors could have easily have gone after their patients. But, they probably realized that there was no way some of these women would be able to pay these amount so they went after the "bigger pockets" and sued the insurance companies. They were able to get an ignorant and sympathetic jury that probably thought that the "insurance company can afford it" and just gave the doctors what they want.

And, let's face it -- with Louisiana citizens having to pay absurd amounts for homeowner's and flood insurance, the doctors couldn't have chosen a better jurisdiction to bring their case. Insurance companies in Louisiana are EXTREMELY UNPOPULAR.

Again, the only possible exception might be with the exact language and terms of the "preapproval." If the insurance company's preapproval was simply that they would pay the "out-of-network" rate (i.e., they'd pay SOMETHING and wouldn't be completely denying coverage because it was some sort of "experimental" or non-covered or elective procedure), then this should have been a matter of summary judgment in favor of the insurance company. I suspect that is what happened here. Coverage wasn't denied as some sort of "elective" procedure (think, nose job or boob job) but the insurance company never agreed or "preapproved" paying anything in excess of their standard and contractual out-of-network rate.