Fort Bend Co. medical practice sues Ill. Blue Cross subsidiary over back claims totaling $19M

By John Suayan | Mar 10, 2016

A Fort Bend County medical provider seeks to recover approximately $19 million in claims on nearly 900 patients from an Illinois-based subsidiary of Blue Cross Blue Shield, according to a federal lawsuit filed Mar. 4 in Sherman.

Elite Center for Minimally Invasive Surgery, LLC asserts that Health Care Service Corp., doing business as Blue Cross Blue Shield of Illinois, was the plan administrator for claims made against its patients’ Blue Cross Blue Shield health benefit plans for medical services performed at its surgical facility.

Per court documents, the defendant administered each and every claim at issue, but remitted “a mere $1,218,833.11, which is approximately 6.05 per cent of the amount billed for the services rendered.”

“Prior to scheduling or performing any medical services, the plaintiff called the defendant at its designated telephone number to verify covered health benefits, including out-of-network benefits and coverage for the particular medical services to be performed,” the suit says.

“It is well understood within the medical field and within the healthcare insurance industry that out-of-network benefits are paid at providers’ usual and customary rates.”

The complainant further asserts that it was supposed to be reimbursed after it obtained the verifications of benefits from the respondent, stating the latter represented that the reimbursement came in the form of “the usual and customary rate for the medical services provided.”

The defendant, however, “denied the claims outright or drastically underpaid the claims” after the practice “properly and timely submitted” the subject claims.

“Payment of 6.05 per cent of the usual and customary rates for same or similar medical services rendered is dramatically lower than any other of the plaintiff’s commercial insurance payers, including United, Cigna, and Aetna, and is tantamount to no payment at all,” the original petition argues.

Attorney David W. Bergquist of the Bergquist Law Firm in Houston serves as the complainant’s counsel.

Sherman Division of the Eastern District of Texas Case No. 4:16-CV-00573

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