Four HCA Healthcare-affiliated hospitals in Texas have sued Pennsylvania-based insurer Independence Blue Cross over alleged claim denials and disputed reimbursement payments.
The plaintiffs include Methodist Health 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 affiliated with Nashville, Tenn.-based HCA Healthcare.
The lawsuit, filed in federal court in Pennsylvania, alleges that Independence Blue Cross was required to reimburse the hospitals under the BlueCard Program, which allows members of the Blue Cross Blue Shield Association to access care when they receive services in another Blue Cross Blue Shield licensee's service area.
The hospitals have contracts with Blue Cross Blue Shield of Texas. The complaint also alleges that Independence Blue Cross represented the hospitals as participating, or “in-network,” providers.
Hospitals allege at least $345,319 is owed
According to the complaint, Independence Blue Cross owes the hospitals at least $345,319 under the agreement.
The hospitals also cited alternative legal theories, including an implied-in-fact contract, in challenging the insurer's reimbursement practices.
Disputed claims and denial reasons
The complaint involves claims associated with eight patients. Alleged reasons for the denials included lack of prior authorization, lack of medical necessity and other reimbursement-related criteria.
The hospitals also allege potential violations of federal and state laws. The complaint argues that certain emergency services do not require prior authorization and that such services should nevertheless be reimbursed.
The allegations have not been adjudicated by the court.
Jefferson Health has separate payment dispute with IBX
Independence Blue Cross is also facing a separate payment dispute involving Philadelphia-based Jefferson Health.
Jefferson sued IBX over nearly $100 million in disputed payments. The case was transferred from state court to federal court and is now facing a motion seeking dismissal.
Independence Blue Cross told Becker's Hospital Review that it does not comment on pending litigation.
