Five Texas hospitals affiliated with HCA Healthcare have sued Independence Blue Cross, a Philadelphia-based Blue Cross Blue Shield plan, alleging that it wrongly denied or underpaid more than $345,000 in claims for eight of its members, Healthcare Dive reported. The hospitals say some of the denied claims were for emergency care.
The allegations have not been proven in court. Independence Blue Cross said it does not comment on pending litigation.
The dispute matters to patients who carry a Blue Cross card from one state and get care in another, whether they are traveling, studying, or living away from their plan's home area.
What the Hospitals Allege
The plaintiffs are HCA Houston Healthcare North Cypress, HCA Houston Healthcare Medical Center, and The Woman's Hospital of Texas, all owned by HCA, along with Methodist Healthcare System of San Antonio and St. David's Medical Center in Austin, which are affiliated with HCA through joint ventures. The lawsuit was filed September 11 in federal court in Pennsylvania, Becker's Payer Issues reported.
The claims date from 2022 to 2024. The hospitals allege that the insurer denied payment for medically necessary services by citing lack of prior authorization, lack of medical necessity, and coding issues. They say the insurer owes at least $345,319.
The lawsuit alleges that Independence required prior authorization for emergency care, in violation of federal and state law. It also claims the insurer failed to provide specific clinical reasons for its denials or to conduct proper medical necessity reviews on appeal. Independence has not publicly responded to the specific allegations.
A Long-Running Fight Over the BlueCard Program
All of the claims ran through the Blue Cross Blue Shield Association's BlueCard Program, which links independent Blue plans into one national network. It lets a member of one plan receive in-network care from providers that contract with a Blue plan in another state. In this case, the Texas hospitals contract with Blue Cross and Blue Shield of Texas.
The program has long drawn criticism from providers, and the case highlights how prior authorization rules and standards for medical necessity can vary from plan to plan, STAT reported.
In a national antitrust case, a judge approved a $2.8 billion settlement between the Blue Cross Blue Shield Association and providers. Some large health systems, including the Mayo Clinic, Children's Hospital of Philadelphia, and Mass General Brigham, opted out of the settlement to pursue their own cases.
Independence faces other payment disputes. Philadelphia-based Jefferson Health sued the insurer in July over nearly $100 million in disputed payments, Becker's reported. That case has since moved to federal court and faces a motion to dismiss.
Emergency Care Rights Patients Should Know
Lawsuits between hospitals and insurers are usually about who pays, not what a patient owes. Still, denials can affect patients through billing delays, collection notices, or confusion about coverage.
Federal law offers strong protection in emergencies. Under the No Surprises Act, most private health plans must cover emergency services without requiring prior authorization and must apply in-network cost sharing, even when the care is provided out of network.
People most likely to face cross-state billing disputes include travelers, college students attending school out of state, retirees who split their time between states, and families whose employer plan is based in another state.
Denials can stem from paperwork as well as medical judgment. A missing authorization number or a coding error can be enough to trigger a rejection, which is why records matter.
Steps to Take if a Claim Is Denied
Read the explanation of benefits carefully. It should state the reason for the denial and the deadline to appeal. Before paying, call the hospital billing office and the insurer to confirm whether the claim is still in dispute between them.
Ask for the specific clinical reason for any medical necessity denial and request a copy of the criteria used. File an internal appeal before the deadline, and ask your doctor to send supporting records. If the internal appeal fails, most plans must offer an independent external review.
Keep copies of every bill, letter, and call log. If you believe an emergency claim was denied for lack of prior authorization, cite the No Surprises Act protections in your appeal and contact your state insurance department for help.
Do not delay emergency care because of insurance concerns. Chest pain, trouble breathing, signs of stroke, severe bleeding, or a sudden severe headache require calling 911 or going to the nearest emergency department. In the lawsuit, the next step is the insurer's formal response in court.
Key Questions Answered
Who is suing whom? Five HCA-affiliated hospitals in Houston, San Antonio, and Austin sued Independence Blue Cross, a Philadelphia-based Blue Cross Blue Shield plan, in federal court in Pennsylvania.
How much is at stake? The hospitals say the insurer owes at least $345,319 for claims involving eight members from 2022 to 2024.
What do the hospitals allege? They allege wrongful denials based on prior authorization, medical necessity, and coding, including prior authorization requirements for emergency care.
How did the insurer respond? Independence Blue Cross said it does not comment on pending litigation. No court has ruled on the claims.
What is the BlueCard Program? It is a national network that lets members of one Blue plan receive in-network care from providers contracted with a Blue plan in another state.
Can insurers require prior authorization for emergency care? Under the No Surprises Act, most private plans must cover emergency services without prior authorization and at in-network cost sharing.
What should patients do after a denial? Read the explanation of benefits, confirm the claim's status, file an appeal on time, request an external review if needed, and keep records.
Published by Medicaldaily.com
