Blue Cross Defrauded Breast Cancer Center, Must Pay $421M, Jury Finds -- ProPublica

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https://www.propublica.org/article/blue-cross-blue-shield-louisiana-insurance-lawsuit-breast-cancer-doctors

“Slow Pay, Low Pay or No Pay”
by T. Christian Miller

Reporting Highlights

Shortchanged: Blue Cross Louisiana OK’d mastectomies and breast reconstructions for women with cancer but refused to pay a hospital’s full bills. For some claims, it paid nothing.

Exceptions: Blue Cross denied payments for thousands of procedures involved in breast reconstruction. But it approved special deals for treatment for executives’ wives.

Verdict: A jury found Blue Cross liable for fraud and awarded the hospital $421 million. The insurance company denied wrongdoing and has appealed.

These highlights were written by the reporters and editors who worked on this story.

On a late afternoon in November 2017, Witney Arch told her 1-1/2-year-old son to stop playing and come inside. Upset, he grabbed her right breast when she picked him up. She experienced a shock of pain but did not think it was anything serious. A week later, however, the ache had not subsided. After trips to several doctors, a biopsy revealed that Arch had early-stage breast cancer. Her surgeon told her that it was likely invasive and aggressive.

. . .

The center’s lawyers paid close attention to Cates as he reviewed the jurors’ decision. It was a two-page form. If the jurors found in favor of Blue Cross, the judge would have no reason to read on. Cates flipped to the second page: The jurors had found Blue Cross liable for fraud. “Please express in dollars the total monetary compensation, if any, Blue Cross owes the hospital and the center for the damages,” Cates said, reading from the verdict. “Net damages, $421,488,633.” The center’s lawyers stood and shook hands as the insurer’s attorneys prepared to leave the courtroom.

. . .

In the months since the judgment, Blue Cross has not changed its practices, the doctors said. It has not approached with an offer that would bring the hospital in network. It still issues prior authorizations for women’s surgeries. And it still pays only a fraction of the billed fees.