Doctors at the Center for Restorative Breast Surgery (“Breast Center”) and St. Charles Surgical Hospital (“Hospital”) in New Orleans, sued Blue Cross Blue Sheild, claiming the insurer tried to coerce the doctors into their network. The Breast Center and the Hospital provide specialized care and treatment for breast cancer, including mastectomies and reconstructive surgery using natural tissue. In fact, the Hospital is the only free-standing hospital in the word focused on breast cancer and reconstructive breast surgery.
The Breast Center and Hospital, which were out of network for health insurance plans, took care to ensure that they received preauthorization for each procedure before services were performed. However, despite receiving preauthorization, Blue Cross either failed to pay the claim, paid a low amount, or took far longer to pay than was necessary. According to the evidence presented at trial, Blue Cross authorized more than 7,000 procedures and paid roughly 9% of the costs for those procedures. The case included claims for fraud and abuse of rights.
A world-renowned plastic surgeon, Dr. Frank DellaCroce, attracted thousands of patients to the Breast Center and Hospital seeking his expertise in reconstructive surgery. As he explained, “[t]o have a woman come to my clinic the day before her surgery and tell me that she’s been called by a nurse navigator to tell her that there are other surgeons in the community that they might deem as being more affordable, yet maybe without as much expertise. They come in with tears over that, that added stress in a moment of crisis is unacceptable to me.”
The case wound its way through the legal system for more than 7 years before finally getting to a jury. After a 3-week trial in Orleans Parish Civil District Court, the jury deliberated for less 2 hours and returned a verdict of $421 million.
Blue Cross plans to appeal.
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