MAPD Denies Claim, Patient Sues

[somarco]

Blue Cross and Blue Shield denied payment for the proton therapy Robert “Skeeter” Salim’s doctor ordered to fight his throat cancer. But he was no ordinary patient. He was a celebrated litigator. And he was ready to fight.

Salim decided to do what few people can afford to do. He paid MD Anderson $95,862.95 for his proton therapy and readied for a battle with Blue Cross, the biggest insurance company in Louisiana.

Many insurers won’t pay for certain specialized or expensive treatments unless a patient gets approval in advance. Blue Cross and other health plans often farm out those reviews to companies like AIM. The insurance industry maintains such companies keep health care costs down and help patients by rejecting unnecessary and unproven treatments.

Salim is expecting the full $95,862.95 he paid. However, court records show that Blue Cross has said it only needs to pay Salim the discounted rate it had negotiated with MD Anderson at the time of his radiation treatment: $35,170.47. That’s what Blue Cross would have paid if its doctors had said yes in the first place.

The case started in August, 2018 and is still being fought by Elevance Anthem Blue Cross

[EXTERNAL LINK] - Insurance Denied a Lawyer’s Cancer Therapy. So He Took Them to Court. — ProPublica

 

[goillini52]

Blue Cross and Blue Shield denied payment for the proton therapy Robert “Skeeter” Salim’s doctor ordered to fight his throat cancer. But he was no ordinary patient. He was a celebrated litigator. And he was ready to fight.

Salim decided to do what few people can afford to do. He paid MD Anderson $95,862.95 for his proton therapy and readied for a battle with Blue Cross, the biggest insurance company in Louisiana.

Many insurers won’t pay for certain specialized or expensive treatments unless a patient gets approval in advance. Blue Cross and other health plans often farm out those reviews to companies like AIM. The insurance industry maintains such companies keep health care costs down and help patients by rejecting unnecessary and unproven treatments.

Salim is expecting the full $95,862.95 he paid. However, court records show that Blue Cross has said it only needs to pay Salim the discounted rate it had negotiated with MD Anderson at the time of his radiation treatment: $35,170.47. That’s what Blue Cross would have paid if its doctors had said yes in the first place.

The case started in August, 2018 and is still being fought by Elevance Anthem Blue Cross

[EXTERNAL LINK] - Insurance Denied a Lawyer’s Cancer Therapy. So He Took Them to Court. — ProPublica

Looks like he's going to be out $60,000 since HE didn't have a negotiated price with the hospital like BCBS did.

 

[LostDollar]

Looks like he's going to be out $60,000 since HE didn't have a negotiated price with the hospital like BCBS did.

But MD Anderson might have sued him for the full $96K. I think it is legitimate for him to expect the full amount from his insurance.

 

[ValeRosso]

If more people were litigators, I suspect MAPDs would change pretty quickly.

 

[somarco]

Looks like he's going to be out $60,000 since HE didn't have a negotiated price with the hospital like BCBS did.

He's a lawyer . . . what do you expect?

If more people were litigators, I suspect MAPDs would change pretty quickly.

When I wrote individual health insurance (under age 65 and before Obamacare) most of the carriers I worked with would not issue policies to lawyers

 

[goillini52]

But MD Anderson might have sued him for the full $96K. I think it is legitimate for him to expect the full amount from his insurance.

I had a bill from an anesthesiologist (who wasn't even there) and an assisting anesthesiologist. BCBS didn't want to pay for both. The hospital sent me a $2,000 bill for what they only billed BCBS about $450. When I pointed that out to them, they told me that I didn't have a negotiated price with them like BCBS did.

BCBS did end up paying for both. This was O'bamacare, before I got Medicare.

 

[rmhaire]

He should go back and tack on attorney's fees

 

[axeman462]

Wait a minute! An insurance company DENIED a claim, and the customer sued???

This is completely unheard of! Thank God this never happens I'm any other line of insurance.

And for the love of God. Nobody tell John Morgan!!!

 

[DS4]

When I wrote individual health insurance (under age 65 and before Obamacare) most of the carriers I worked with would not issue policies to lawyers

On the group side in California, I had a 2 page list of excluded occupations. Dr offices, Attorney offices, logging companies, etc etc.
On the individual side, you only had to pass underwriting.

 

[StephanieCJ]

If you read the article, it does not say anything about him having an MAPD. It says he paid Blue quite a bit for insurance for himself and employees of his practice, which would indicate a group plan to me...