Illinois’ largest health insurance company will pay $25 million to settle allegations that it denied coverage to sick children in need of nursing care by “fraudulently” shifting their claims to Illinois’ Medicaid program, state and federal prosecutors said this morning.
The settlement, reached by Illinois Attorney General Lisa Madigan and U.S. Attorney Patrick Fitzgerald, follows several years of complaints from patients and their families. The patients reached out to Madigan’s office after their claims were denied by Blue Cross and Blue Shield of Illinois.
The cost of the medical care, which included so-called private-duty nurses for sick children and other ill patients, should have been covered by Illinois Blue Cross, but instead was shifted to Medicaid at a cost of nearly $12 million, prosecutors said. The claims were denied based on “internal, undisclosed guidelines that were more restrictive than the language provided to patients in plan policy materials,” Madigan’s office said.
“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.”
Because the Medicaid health insurance program for the poor is funded by state and federal tax dollars, the state of Illinois and the U.S. Treasurer will share in the proceeds from the settlement. Illinois Blue Cross will pay the state $14.25 million. Another $9.5 million will go to the federal government to reimburse the Medicaid program. $1.25 million will go to Illinois consumers who were denied coverage by Illinois Blue Cross but did not receive Medicaid coverage.
“Blue Cross Blue Shield’s inappropriate denial of legitimate claims placed an undue burden on the state’s finances,” Madigan said. “My office is committed to holding health care insurers accountable on behalf of the people of Illinois for this type of deception and fraud.”
For its part, Illinois Blue Cross said it disagreed with the allegations and denied any “inappropriate conduct,” the company said in a statement to the Tribune.
“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,” Illinois Blue Cross spokesman Jack Segal said. “These plans and polices determine which benefits are covered and which are not. 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.”
Way to go Lisa. You’re the best.
Have no concern at all. We are working hard to keep government boureaucrats from coming between you and your doctor. If a few kids get whacked in the processs…welll, all the better to keep socialism from CREEPING.
Or, whatever.
Lisa will be the best when she indicts her corrupt father.
Blue Cross and Blue Shield of Illinois is a corrupt corporation. They are expanding their headquarters, which is costing them millions of dollars, at the same time they are shifting their responsibilities to the taxpayers of the State of Illinois. Fitzgerald should criminally prosecute their corrupt executives.
The day they are both indited.
How does the Atty. General determine what consumers get the 1.25 million? I know that BC/BS has denied plenty of my claims & I was not elegible for Medicaid.
Nice to see the families with sick childeren got screwed again. With the money they are getting from BCBS is it possible to lower my income taxes? Thank you Govenor Quinn
BC/BS has thousands of these “undisclosed internal guidelines.” The aim? To make it as tough as possible for the premium payer to get his/her claim paid. I’ve spent 15 years trying to help patients understand these arbitrary decisions, and I don’t feel any closer to understanding BC now than the day I started. Corrupt? Yes, from where I sit.
‘The State of Illinois and the U.S. Treasurer will share in the proceeds from the settlement. Illinois Blue Cross will pay the state $14.25 million. Another $9.5 million will go to the federal government to reimburse the Medicaid program. $1.25 million will go to Illinois consumers who were denied coverage by Illinois Blue Cross but did not receive Medicaid coverage.’
Big surprise there, those who got screwed get screwed again.
BC/Bs’s days are numbered. Fewer and fewer private employers can afford to provide health insurance. BC/BS is one of the most expensive. Government employees make up a larger and larger percentage of the people covered by BC/BS. But, with their finances in shambles, fewer and fewer public entities will be able to offer BC/BS to their employees. The day of reckoning is coming, for BC/BS and for all of us.
We must let the private insurance market monopoly operate without government interference (except the tax breaks and monopoly protection and secrecy). Anything else is socialism which will turn this country into North Korea.
If Blue Cross had double secret internal guidelines that caused these claims to be rejected, we must honor Blue Cross’s decision and Lisa Madigan should not interfere.
Palin 2012!
Blue Crossand Blue Shield are just as sleazy in California.
Yep, we sure do want to leave insurance coverage with corrupt, greedy, corporations who have no qualms about letting kids die. Why isn’t Palin shooting her mouth off about these ‘death panels’?
BSBS has always provided excellent service for me. I’ve received a LOT more than I’ve paid. Sure, I’ve had some denied but overall they have done what they are suppose to.
While the government is likely to be rather inept at handling health care, at least the government is not a crooked profiteering insurance company like bc/BS (emphasis on BS). I don’t understand the resistance to letting the government take over health care, in favor of paying big bucks to crooks who deny health care at wiil, and gouge us on premiums.
Hey ‘Watcher’, if you have received a LOT more then you have paid, it is because people like me are paying a lot more than we received. We are subsidizing you…lay off the Cheetohs and do some exercise, please.
Blue cross/blue Shield in NY is horrible too.
If Illinois politicians have any brains at all, they will use the money to pay down our debt. I know this is asking a lot, but a miracle could happen.
Makes you proud to be an american with the best health care in the world.
Just when you think American Companies can’t do anything worst, they always pull some new move out of their ***** and really lower the bar! A lot of business people are going to fry on judgement day. Good luck trying to lie and buy your way out!!! Oh, don’t even think that giving your money away in your old age will absolve you!
They are thiefs, no doubt. Spent 6 months trying to get them to pay for Autism related treatment. Had to get our State Rep. Kevin McCarthy involved. He is the best. Took our calls directly, and made calls on our behalf. He got it fixed. How can a goverment agency that low bids everything it supposedly does, repeatedly sign BCBS to new contracts…KICKBACKS?