business

Illinois Blues settles charges of passing costs to Medicaid

An investigation finds the plan had internal guidelines for coverage that were stricter than those given to members.

By Emily Berry — Posted March 16, 2011

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

Blue Cross Blue Shield of Illinois has agreed to pay $25 million to settle allegations that the company deliberately denied coverage for private duty nursing for severely ill adults and children in order to shift the cost of care to Medicaid.

A government investigation showed that Illinois Blues had internal standards for coverage that were stricter than the rules given to members, according to Chicago-based U.S. Attorney Patrick Fitzgerald and Illinois State Attorney General Lisa Madigan. The plan also is accused of fraudulently denying coverage when members appealed the initial denials.

The plan, owned by Health Care Service Corp., disputes the government's claims and said it settled to avoid more costly litigation. In the settlement, the Illinois Blues did not admit wrongdoing.

"This dispute began many years ago when we reviewed certain claims and determined that the benefits sought were not covered by the applicable insurance plans and policies," a company statement said. "Several years ago, in cooperation with the state attorney general, we expanded our explanation of benefits to ensure that our members understood what nursing benefits are covered under their plans. That action, coupled with today's agreement, are in the best interests of our members."

The insurer passed on $12 million in expenses to the state that should have been paid under members' coverage, according to the attorney general and the U.S. attorney's office.

The company will pay $14.25 million to Illinois, $9.5 million to the U.S. government and $1.25 million to consumers the government says were denied coverage by Blue Cross Blue Shield but were not covered by Medicaid.

"Blue Cross Blue Shield's inappropriate denial of legitimate claims placed an undue burden on the state's finances," Madigan said in a statement. "My office is committed to holding health care insurers accountable on behalf of the people of Illinois for this type of deception and fraud."

Back to top


ADVERTISEMENT

ADVERTISE HERE


Featured
Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story


Read story

Goodbye

American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story


Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story


Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story


Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story


Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story


Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story


Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn