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Started By
Message
re: A $421M jury award against Blue Cross heads to the Louisiana Supreme Court
Posted on 8/31/26 at 10:51 am to BugAC
Posted on 8/31/26 at 10:51 am to BugAC
quote:
You do know you are not forced to have health insurance, right? You are welcome to pay out of pocket for your medical costs.
Thank you for giving me your blessing to pay for things. Why do you even bother to respond to anything I post? Just wanting to be adversarial?
1
Posted on 8/31/26 at 10:54 am to 4cubbies
Were I the Hospital Administrator, it wouldn't take "thousands of cases" to stop accepting BC/BS. I would assume the insurance declined the cases because it's cosmetic surgery and considered elective?? I don't know why they were denied. Be relevant to the discussion.
Posted on 8/31/26 at 10:56 am to Diamondawg
quote:
I would assume the insurance declined the cases because it's cosmetic surgery and considered elective??
The provider was out of network.
Posted on 8/31/26 at 10:58 am to Diamondawg
There was a thread when the verdict occurred. At the time it seemed like the hospital tried gaming the system. They refused to join the network because they knew there were no alternative providers in the area that provided their services. As a result they assumed BCBS would be trapped and forceed to pay whatever rate they billed.
Posted on 8/31/26 at 11:04 am to 4cubbies
quote:
Thank you for giving me your blessing to pay for things. Why do you even bother to respond to anything I post? Just wanting to be adversarial?
I posted more than just that. It's a discussion board, on a thread YOU started. If you don't want anyone to respond to you, dont' start a thread. I'm sorry i crapped on your "insurance is the devil" thread that you wanted to start. You'll get over it.
Posted on 8/31/26 at 11:05 am to lsuconnman
quote:
They refused to join the network because they knew there were no alternative providers in the area that provided their services. As a result they assumed BCBS would be trapped and forceed to pay whatever rate they billed.
This does seem odd, racking up $421 million in bills, or $655 million as it stands now, and not questioning, or halting surgeries, or doing anything before the billing amount got so high.
Posted on 8/31/26 at 11:08 am to lsuconnman
I have no love for the big 5 insurers, but a facility selectively choosing to remain OON over the course of 7 years deserves every negative outcome they get. It's 100% a business strategy to increase overall reimbursement, with balance billing the patient after the low/no reimbursement from the insurer being a large revenue factor. It's dirty AF. It's double dipping in hopes of maximizing revenue from both insurer and patient. Anesthesiologists, ambulance companies, and free standing ERs are usually the worst offenders in my experience.
It sounds like BCBS didn't play the game, pushing the financial burden to patients who likely can't afford it. I have alot of empathy for insurance ignorant patients who don't understand where this large oon patient balance came from. And ZERO pity for the Healthcare institution who knowingly took the risk of remaining OON and got burnt.
It sounds like BCBS didn't play the game, pushing the financial burden to patients who likely can't afford it. I have alot of empathy for insurance ignorant patients who don't understand where this large oon patient balance came from. And ZERO pity for the Healthcare institution who knowingly took the risk of remaining OON and got burnt.
This post was edited on 8/31/26 at 11:13 am
Posted on 8/31/26 at 11:11 am to Diamondawg
quote:
Were I the Hospital Administrator, it wouldn't take "thousands of cases" to stop accepting BC/BS
100%. They played the long game and got burnt.
Posted on 8/31/26 at 11:12 am to BugAC
quote:
I'm sorry i crapped on your "insurance is the devil" thread that you wanted to start.
Did my post explicitly stating "It's impossible to pick a good guy here," cause you to draw that conclusion?
I didn’t say you shouldn’t respond. I asked why so many of your responses to me are aimed at contradicting something I didn’t actually say.
Posted on 8/31/26 at 11:22 am to 4cubbies
I guess this is a 'BCBS' post within another thread. Doctor prescribed Jardiance around Christmas last year. Company I worked at the time was HQ in SC so we had 'Blue Cross of South Carolina.' No problem. Left them in May for another job so had to go on the Mrs insurance for a month. She had Blue Cross of Alabama.' No problem.
New company I'm at has 'Anthem' some other BCBS identiy. Jardiance "denied." I don't get it.
New company I'm at has 'Anthem' some other BCBS identiy. Jardiance "denied." I don't get it.
Posted on 8/31/26 at 11:23 am to BugAC
quote:
The New Orleans-based hospital and center, founded by surgeons Frank DellaCroce and Scott Sullivan, specialize in autologous tissue breast reconstruction after mastectomy. They left the Blue Cross network in 2007 over reimbursement rates and have since operated as out-of-network providers. They continued treating Blue Cross patients after receiving prior authorizations that the procedures were medically necessary.
Even if medically necessary, not an emergency surgery; this argument should go in BCBS's favor
quote:
From 2015 to 2023, they billed for roughly 7,800 such procedures. Blue Cross paid about 9% of the billed amounts on average; many claims received no payment. The hospital alleged it did not balance-bill patients and absorbed the shortfall.
Had sinus surgery under similar circumstances at a surgical facility in Metairie (sinuses impacted due to 2 prior broken noses from playing youth sports). If this is a common practice, and based on the language they used in their contracts with their patients; the facility probably should lose based on this practice as well.
*For mine, they acknowledged that they were out of network, would only charge me as if they were my in-network provider, and would disputes with my insurance company (ironically BCBS) for the balance.
Posted on 8/31/26 at 11:25 am to Weekend Warrior79
quote:
They continued treating Blue Cross patients after receiving prior authorizations that the procedures were medically necessary.
With every PA that comes back..."Approval of this prior authorization is not a guarantee of reimbursement." Every. Single. One.
This post was edited on 8/31/26 at 11:26 am
Posted on 8/31/26 at 11:26 am to 4cubbies
quote:
Insurance company people threatening the courts with increased premiums if the case isn't dismissed. As if premiums wouldn't increase otherwise. Insurance companies are the least sympathetic victims imaginable.
Naaaahhhhh.. we got Obamacare passed. The ole "signature" health plan. This would neeeeeever happen. Caaaaant happen. Noooooothing the opposition was saying was going to happen. This is allllllll scare tactics and fear mongering by the opposition.
Posted on 8/31/26 at 11:27 am to lake chuck fan
quote:
Is "reconstructive breast surgery" the same as breast implants???
Some clinics specialize in taking tissue from one part of the body to rebuild breast tissue for mastectomy patients, rather than using implants. Health plans are required to cover breast reconstruction post-mastectomy, but are not required to cover any and all reconstruction techniques. Using fat from other parts of the body is much more expensive (multiple times the cost of implants). Add to that being out of network and asking for "rack rates" on surgeries, they've conjured up a $400M claim that apparently went over well with an Orleans Parish jury. Providers tend to sue the insurers (and employers with self-insured plans) to try to negotiate increased payments.
When a family friend had reconstructive surgery she went the natural tissue route and had fundraisers to "save the ta-ta's" and help cover the amount not covered by insurance.
Balloon sinuplasty centers are mostly out of network as well, and now ABA therapy providers for autism are shaking down insurers and employers for big $$, while not being in network. Not to mention ambulance providers.
Posted on 8/31/26 at 11:34 am to Diamondawg
quote:
Were I the Hospital Administrator, it wouldn't take "thousands of cases" to stop accepting BC/BS. I would assume the insurance declined the cases because it's cosmetic surgery and considered elective?? I don't know why they were denied. Be relevant to the discussion.
That is the real heart of the case. BCBS wants it treated as a straight contracts dispute because they will win every time: "Prior authorization" does not mean "will pay" - whether 9% or 100% or anything in-between. Plaintiffs have to be alleging so sort of intentional or negligent use of "prior authorization" for their own gain and/or to harm the providers.
I have no idea what that could be, but it has to be the heart of the dispute.
Posted on 8/31/26 at 11:35 am to 4cubbies
quote:
The patients are the good guys (gals) and the losers.
Sounds like they got treated, and the hospital ate the charges. The patients don't sound like losers to me.
Posted on 8/31/26 at 11:39 am to MSMHater
quote:
With every PA that comes back..."Approval of this prior authorization is not a guarantee of reimbursement." Every. Single. One.
Which sort of renders the whole process pointless.
Posted on 8/31/26 at 12:32 pm to Cosmo
quote:
Plenty of medicaid patients also get breast reconstructions after cancer
And people who get their foot lopped off get a prosthetic foot too. No difference.
Posted on 8/31/26 at 12:32 pm to REG861
quote:
I am not a fan of big health care insurance but BCBS is generally speaking one of the good ones. I have zero faith that an Orleans jury was capable of comprehending the nuances of the issues at stake.
I can’t believe it, but I concur. BCBSLA has not denied anything but genetic testing for my daughter who has had crazy amounts of mri’s, scans, and even a venogram over the last 2 years. The crazy part is the genetic testing is way cheaper than any of the other stuff.
Posted on 8/31/26 at 12:39 pm to 4cubbies
Hey Cubbies-BFF-I have insurance through AmBetter. I am self-employed. I tore my meniscus in May and am in extreme pain and with very limited mobility. The Baton Rouge clinic ran numerous tests and so forth-MRI-weeks of physical therapy just for them to tell me that I would not be getting the surgery they recommended-because they were no longer honoring AmBetter. AmBetter -then sent me a list of orthopedic surgeons with about 50 names-none of whom will accept AmBetter. So I have thousands of dollars in bills, an 8500-dollar deductible, a shite ton of PAIN, and all I have to show for it are bills and a GHOST network of doctors which they used to entice me to enroll with them. It's LITERALLY worthless. I pay thousands and yet cannot find treatment. Were I on Medicaid I would have already had a knee replacement.
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