Inside these posts: Health care claims

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Illinois Blue Cross settles allegations that it denied sick kids coverage

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. Get the full story »

Fewer claims lift WellPoint, Aetna in 3Q

WellPoint Inc. and Aetna Inc. raised their profit forecasts for the year as members avoided doctor visits or delayed care to save money, while the large U.S. health insurers stand to see an improved political climate for their business under the new Congress.

Both reported higher-than-expected quarterly profits Wednesday, saying they benefited from having to pay out less in medical costs. Get the full story »