NEW ORLEANS — It took a New Orleans civil jury only two hours to unanimously decide, that the state's largest health insurance provider, Blue Cross Blue Shield of Louisiana, committed fraud, and abused the rights of local doctors.
They are local doctors internationally renowned for breast reconstruction in cancer patients, who have created sophisticated surgical procedures not being done at other centers.
Blue Cross says it strongly disagrees with the verdict, and will quickly appeal and expects to win.
The jury wants Blue Cross to pay the doctors’ practice $420 million for unpaid claims.
As a mother of four, and only in her mid-40s, Witney Arch discovered she had breast cancer. She knew she wanted her double mastectomy and reconstruction at the Center for Restorative Breast Surgery in New Orleans.
“I was not going to go anywhere else, because these are the doctors that are pioneers in this industry, and they teach other surgeons around the world how to do my very surgery,” said Witney Arch, 49, of Mandeville.
That center and its specialty physicians are out of the Blue Cross network. She says Blue Cross Louisiana called her with names of in-network doctors who would cost less.
“I've done my research, and I was like, ‘I feel very confident that this is where I want to go,’” Arch told BCBS.
Cancer survivor and founder of Breastoration Foundation, Kim Sport says by law insurance companies must pay for reconstruction and can not reduce benefits for the patient, nor the reimbursement owed to the physician.
“We have seen a trend nationwide, and by insurers in the state of Louisiana, to try to discourage or disincentive access to these advanced surgeries to women that need reconstruction following their mastectomy," said Kim Sport, who is also the President of the Cancer Association of Louisiana.
So, in 2017, the surgeons at The Breast Center sued Blue Cross Louisiana, saying that for nearly 10 years, and 9,000 procedures, the insurance company did not reimburse them for procedures they gave prior authorization to.
“Blue Cross either slow paid, low paid, or no paid, all of those bills for the last eight years. They wanted to pressure the doctors and the hospital to come into their network,” said James Williams of Chehardy Sherman Williams Law.
The lead trial attorney, James Williams says Blue Cross of Louisiana also had a side deal when patients came from out of state and had insurance with BCBS in another state.
“Blue Cross Louisiana was able to make 16 percent of whatever amount of money they saved off of the price,” said Williams.
“Blue Cross Louisiana forcibly intervenes, requires us to send a bill to them.
Blue Cross Louisiana reprices it to Louisiana rates. Who's getting the skim? Really, it's unbelievable,” said Dr. Scott Sullivan, a breast reconstructive microsurgeon who is co-founder of the Center for Restorative Breast Surgery.
Previously, the center's reimbursement from Blue Cross was coded for less advanced and costly surgeries, and the doctors even learned that they were on a doctor target list.
“They even kept a log of the G-file savings from Drs. Sullivan, DellaCroce, and Trahan, and that goes right to the bottom line in profit,” said Dr. Sullivan.
The Breast Center is only asking for reimbursement for unpaid claims. They did not pass the cost on to patients.
In a vote of 11-1, the jury agreed that the total came to more than $421 million.
Blue Cross of Louisiana did not want to be interviewed for this story, but sent the following statement:
“While we appreciate and value the legal process, we strongly disagree with the jury’s verdict. We will quickly appeal and expect to be successful.
Our mission is to improve the health and lives of Louisianians. Part of that mission is to work with network providers to offer high-quality care at fair reimbursements, ensuring our members access to affordable, quality care.
Unfortunately, verdicts like this contribute to increasing healthcare costs for Louisianians who depend on us every day," — Cindy Wakefield, Vice President, Strategic Communications, Louisiana Blue
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