Thread by @txtianmiller

I’ve been reporting on health insurance denials for more than a year. Last fall, I stumbled across a lawsuit that, with interviews, revealed one insurers’ playbook of secret lists, special deals and lowball payments. 👇

In September, a Louisiana jury awarded $421M to a hospital specializing in breast restorations for women with cancer-related mastectomies. Blue Cross, jurors found, committed fraud. documentcloud.org/documents/2589…

Meet Witney Arch, a 42-year-old mom of four. When she found out she had breast cancer, she decided to go to the Center for Restorative Breast Surgery in New Orleans, renowned for its highly specialized approach to post mastectomy breast reconstruction.

Blue Cross gave her prior authorization. Then things got strange. A little before the operation, a representative called to try to convince her to go somewhere else: “Do you know how much this is going to cost?”

Witney wasn’t the only patient who got pushback. Founding surgeons Frank DellaCroce and Scott Sullivan had battled @MyLouisianaBlue in court for 18 years over payments for surgery that Blue Cross agreed was medically necessary.

@MyLouisianaBlue The crux of the case: Blue Cross had approved more than 7,800 procedures related to mastectomies and breast restorations. But it paid only about 9% of the bills for those treatments. And sometimes nothing at all. In fact, 60% of the claims were zero pay.

@MyLouisianaBlue The center argued this was a promise made, but not paid and thus, fraud. Its attorney said Blue Cross’ policy was “Slow Pay, Low Pay or No Pay” propublica.org/article/blue-c…

@MyLouisianaBlue But not all patients’ claims were disputed. One thing Sullivan told me: While Blue Cross haggled over reimbursing for care at the center, which was out of network, it approved special one-time deals that paid for executives’ wives to get surgery there.

@MyLouisianaBlue In the more than 42,000 pages of discovery that Blue Cross dumped on the center’s attorneys: a “targeted” list and a “blocked” list that mentioned DellaCroce, Sullivan and other surgeons at the center. documentcloud.org/documents/2553…

@MyLouisianaBlue But at trial, a Blue Cross employee acknowledged that the disclaimer was not meant as an excuse to free the company from paying bills, and that a prior authorization “usually” resulted in a payment.

@MyLouisianaBlue It also said center doctors were on the lists because of bad billing practices. The extra scrutiny never really slowed things down. “Basically, no harm was done,” one exec said. documentcloud.org/documents/2553…

@MyLouisianaBlue Then there is this: insurance companies almost never pay the full bill from providers. They think that the bills are often inflated or disconnected from actual costs. The center maintained its invoices were fair.

@MyLouisianaBlue If Blue Cross paid out of network doctors’ bill in full, premiums would skyrocket, execs argued. Their goal was to pay for care and keep costs low. Blue Cross has appealed the verdict. The jury “was wrong on the facts and the law,” it said.
documentcloud.org/documents/2589…

The glimpse inside provided by the trial revealed a basic truth: Insurance companies aren’t just players in the fight with doctors over money, they’re also the referees. In the end, it’s not surprising that they often come out ahead.

Read the full story here: propublica.org/article/blue-c…

@MyLouisianaBlue The lists meant that prior authorizations and payments got special scrutiny from Blue Cross which sometimes slowed down payments, the center said.

@MyLouisianaBlue Blue Cross’ main defense was that each prior authorization contained a disclaimer that it was not a guarantee of payment. “Let me be clear: The authorization never says we’re going to pay you,” the former CEO said in a deposition. documentcloud.org/documents/2588…