ProPublica’s Reporting on Blue Cross of Louisiana Reveals the Dark Truth Behind “Prior Authorization”
BCBS of Louisiana ordered to pay $421 million in landmark fraud case.
A ProPublica story titled “Slow Pay, Low Pay or No Pay” is required reading for people who want to know how insurers manipulate the U.S. health care system.
It chronicles the legal case that resulted in a finding of fraud and a $421 million verdict against Blue Cross and Blue Shield of Louisiana. The insurer wanted to pay much less than it was billed to a New Orleans breast surgery center: “Of the 7,837 medical procedures in dispute in the lawsuit, involving 1,680 patients, Blue Cross paid about $43 million on invoices totaling $500 million,” according to the ProPublica story.
The dispute helps readers better understand how the American system works – or doesn’t. The story by T. Christian Miller is presented in four parts, a saga that describes the history of the clinic, the case of the patient with breast cancer, and the practices of the insurer.
In 2017, the Center for Restorative Breast Surgery in New Orleans filed its third lawsuit against the Louisiana Blue Cross, this time claiming fraud in its battle over payments. And this time, a jury found the insurer liable and awarded the center $421,488,633. According to ProPublica, the jury foreman said, “We would have given more if we had been asked for more. That’s how egregious the fraud was.”
ProPublica said its story exposes a “fundamental truth”: Insurers aren't just players fighting with doctors over money. They are also the referees. “Insurers produce their own guidelines to determine whether to pay claims. When a doctor appeals a denial, insurers make all the initial decisions.” The proverbial deck is stacked against the doctor, and ultimately the patient.
One important takeaway from the Louisiana saga is what prior authorization for a procedure means in insurance-speak. That may have relevance for thousands of other patients who believe they have prior authorization for a procedure only to discover they may not get reimbursement in full, or at all. The CEO of the Louisiana Blue Cross noted that while a procedure could be “deemed” medically necessary, it was ‘‘not a guarantee of payment,” a difference patients everywhere should heed.
Miller’s terrific reporting and writing chronicle insurer practices that occur in states beyond Louisiana. “The power in the system is now concentrated in fewer players,” Miller says. “The stories show how much power the insurance companies have in determining how to pay doctors.”
Doctors once dominated the system and set the price of care they provided. This story illustrates how insurers have become the gatekeepers determining the medical services Americans receive. Mega-insurance companies can decree that their products are no guarantees of payment, often leaving patients to pay out of pocket, assume mountains of medical debt, or forgo care.
I asked Miller how he came to produce the story. “What caught my eye was the size of the verdict,” he said. “I knew there would be evidence and documents, and it could be a bigger story of what happened.” Indeed, it is a big story that shows us our health care system is in need of major change.
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The pre-auths always say that there is no guarantee of payment. It is not at all unusual to submit the claim and then find out that there is vastly reduced payment from the pre-auth.
Look into how the insurance company can demand money back for "incorrect" payment on previous claims. In NY, I believe they have two years to do so. It is not at all unusual for them to demand money back just shy of that 2 year mark and then tell us to "just" bill the patient. There is essentially no way to argue with the insurance company over this either. They will simply withhold funds from other patient claims.