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Judge Dismisses Blue Cross Lawsuit Over Low Reimbursement Rates

27 Dec 2018 10:06 AM | AIMHI Admin (Administrator)

D Magazine Source Article | Comments Courtesy of Matt Zavadsky

Interesting outcome that may have implications across the country for emergency medical care providers.  Another signal that we should be partnering with payers on payment models that bring enhanced value to the patient, the provider, and the payer.

For our EMS brethren, note the reporter’s use of the term ‘emergency medical services’ to refer to the care received in the ED

NHTSA and the Red Flash Group are embarking on a project seeking input on terms that most accurately reflects the services provided by out-of-hospital medical care providers working on ambulances and First Response vehicles. 

NEMSAC and some professional organizations have recommended use of the term “paramedicine” as the services we provide, whereas “EMS” in its purest sense was originally intended to represent a ‘system’ of care, including pre-hospital, inpatient and post-hospital care.

We encourage all who are invited to provide input into this project to do so.

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Judge Dismisses Blue Cross Lawsuit Over Low Reimbursement Rates

12/21/2018by Will Maddox|

A federal judge has dismissed a lawsuit against Blue Cross Blue Shield of Texas by 49 physician groups that claim the insurer is not paying enough for emergency medical care.

The groups argue  there are 250,000 claims where Blue Cross’ reimbursement rate for out-of-network providers violates Texas insurance laws and regulations.

In an emergency, patients are brought to the nearest hospital, which might not always be in network. “As out-of-network providers, the Provider Entities are not contractually bound to accept discounted rates of payment for the emergency medical services they provide to BCBSTX Members and instead expect to receive their billed charges for these services,” the lawsuit reads.

The 49 complainants, who come from all over the state, say that there have been hundreds of thousands of out-of-network claims where Blue Cross has underpaid. “Rather than pay the true and accurate bill generated by the Provider Entities, BCBSTX has knowingly lowered the reimbursement rate allowed for ‘out-of-network’ care to levels below what member plans and applicable regulatory authority require. BCBSTX paid most of these claims at a net payment rate that is significantly less than what the Provider Entities are entitled to receive as out-of-network providers.”

The lawsuit also highlights past action taken against Blue Cross by the Texas Department of Insurance. “TDI found that Blue Cross set its allowable amounts for out-of-network providers at ‘unreasonably low rates that are less than the amounts billed by facilities and also less than the rates paid to BCBSTX contracted facilities.’ TDI also stated that Blue Cross’s “reimbursement rates are so low as to violate Texas insurance laws and regulations.”

Judge Karen Gren Scholer of the U.S. District Court for the Northern District of Texas dismissed the case without explaining the decision, and the physicians have 60 days to file a new complaint with additional support. Due to the appeals process, Blue Cross Blue Shield of Texas had no comment.


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