Louisiana insurer ordered to pay $421M for breast reconstruction surgeries
Nonprofit healthcare payer Blue Cross and Blue Shield (BCBS) of Louisiana failed to fully reimburse a New Orleans surgery center and will be paying $421 million to make amends, a state civil court ruled.
According to a report from NOLA.com, St. Charles Surgical Hospital and Center for Restorative Breast Surgery received the money after a seven-year legal battle. In the end, the center proved to jurors' satisfaction that it had been shortchanged on thousands of breast reconstruction surgeries.
A jury in the case determined BCBS of Louisiana committed fraud, authorizing some 7,800 surgeries between 2015 and 2023, only to then reimburse St. Charles for about 9% of the total claim amount.
The insurer denied the accusation in court and argued that St. Charles was not an in-network provider, thus it was nor obligated to reimburse it for care at all. BCBS of Louisiana also said that prior authorization for treatment is not a contractual guarantee it will pay for care.
The surgery center is not part of the insurer's network. However, it reasoned that, by authorizing the care, BCBS of Louisiana effectively agreed to pay for the breast reconstruction surgeries. The jury ultimately agreed with St. Charles and its attorneys.
St. Charles was founded in 2003 by two doctors, Frank DellaCroce, MD, and Scott Sullivan, MD. The duo opted out of the insurer’s network in 2007 after a dispute over reimbursement rates. Their victory in the lawsuit was the third attempt to sue BCBS of Louisiana. The case had previously been dismissed twice.
The $421 million award is one of the largest civil judgements in the history of the state. BCBS of Louisiana said it will appeal the verdict.
Read the report from NOLA.com at the link below for more details.
Chad is an award-winning writer and editor with over 15 years of experience working in media. He has a decade-long professional background in healthcare, working as a writer and in public relations.