Several HCA Healthcare-affiliated hospitals in Texas filed a lawsuit Sept. 11 against Pennsylvania insurer Independence Blue Cross over alleged claim denials.
The plaintiffs include Methodist Healthcare System of San Antonio, St. David’s HealthCare, HCA Houston Healthcare North Cypress, The Woman’s Hospital of Texas and HCA Houston Healthcare Medical Center — all tied to Nashville, Tenn.-based HCA Healthcare.
The lawsuit, filed in a Pennsylvania federal court, argued the insurer needed to reimburse these hospitals under the BlueCard Program, which allows members of one Blue Cross Blue Shield Association licensee plan to receive covered care access in another licensee’s service area. In this case, the hospitals contract with BCBS Texas. The complaint also said IBX represented the hospitals as “in network.”
The complaint said IBX owes the hospitals at least $345,319 under the agreements. The lawsuit outlines alternative legal theories, such as “implied-in-fact contract,” to challenge IBX’s reimbursement approach, as well.
Among eight patients, common reasons for denials included lack of authorization, lack of medical necessity and other shifting rationales, the complaint alleged. The lawsuit called out possible violations of federal and state laws with the denials, including how emergency care would not require prior authorization and would still need to be paid for.
Philadelphia-based Jefferson Health sued IBX in July over nearly $100 million in disputed payments. That case moved from state to federal court and is now facing a motion to dismiss.
IBX told Becker’s it does not comment on pending litigation.
At the Becker's 5th Annual Fall Payer Issues Roundtable, taking place November 2–3 in Chicago, payer executives and healthcare leaders will come together to discuss value-based care, regulatory changes, cost management strategies and innovations shaping the future of payer-provider collaboration. Apply for complimentary registration now.
