Blue Cross accused of theft in suit

David Yates Sep. 5, 2007, 11:39am

Quality Infusion Care Inc. has filed a lawsuit against Blue Cross Blue Shield of Texas claiming the health insurance provider is stealing from its company – disguising its theft as a "fraudulent accounting entry."

According to the plaintiff's original petition, filed with the Jefferson County District Court on Sept. 4, BCBSTX had approved and accepted insurance claims submitted by Quality, but never paid the money.

"BCBSTX fraudulently made an accounting entry that the amount had already been paid when in fact it never was. BCBSTX did not send the money to Quality," the suit said. "Rather, BCBSTX converted the money for itself claiming that it had previously made a mistake in paying a specific 'initially paid claim.'"

The BCBSTX Web site says, "Blue Cross and Blue Shield of Texas…is Texas born and bred. Our mission since our founding more than 70 years ago has been to provide financially sound health care coverage to as many Texans as possible. We serve more than 4 million members in all 254 Texas counties."

Quality Infusion Care holds a pharmacy license from the State of Texas and specializes in providing infusion care services to its patients, the suit said.

"Over the past several years, Quality has treated many patients who looked to BCBSTX for their health care coverage," the suit said. "Prior to providing such service, Quality obtained pre-approval from BCBSTX. After providing services to those patients, Quality sent certain bills to BCBSTX which BCBSTX paid in due course without protest or question. These claims will be referred to as 'initially paid claims.'

"Several months, sometimes years, after BCBSTX had processed those 'initially paid claims,' Quality provided different services to different patients under different plans. Again, prior to providing the services to this subsequent set of patients, Quality sought and obtained approval from BCBSTX. These claims will be referred to as 'subsequent covered claims.'"

The suit goes on to say BCBSTX admitted that "subsequent covered claims" were covered under the respective BCBSTX plans and that the money was due and owing to Quality. However, Quality contends BCBSTX never paid the company for the claims.

"In each instance, the 'initially paid claim' was completely separate and apart from the 'subsequently covered claim' involving different patients, different employers, and different plans," the suit said. "It is Quality's belief that BCBSTX did not reimburse the money to the plan out of which the 'initially paid claim' was initially allocated.

Quality alleges BCBSTX is guilty of Texas Insurance Code violations, promissory estoppel, conversion, fraud and theft.

Quality is suing BCBSTX for services it provided, money it was paid, and for express and implied promises made by BCBSTX to Quality, plus punitive damages.

The plaintiff is demanding a trial by jury and is represented by attorney Robert Green of the Robert D. Green & Associates law firm.

Judge Milton Shuffield, 136th Judicial District, will preside over the case.

Case No. D179-940

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