BlueCross BlueShield sues for-profit medical center on patient’s behalf

Apr 23, 2014 | Health Insurance Billing

Toby Klar, a professional truck driver from Nashville, awoke the morning of October 24, unable to move his lower body and was violently nauseous. When the ambulance arrived, he asked the drivers between breaths to take him to Saint Thomas Hospital, where his insurance would cover treatment. However, the law dictates that the ambulance crew must report to the nearest facility, which was TriStar Southern Hills. 

TriStar Southern Hills Medical Center, a subsidiary of Nashville-based HCA Holdings Inc., is the largest for-profit hospital chain in the country. Klar, 48, spent four days there recovering from a stroke. Under his insurance agreement with BlueCross, Klar has a deductible and coinsurance totaling about $3000. TriStar determined that the coverage was out of network, and proceeded to bill BlueCross for the amount of $44,000. 

On April 1, BlueCross filed a lawsuit against TriStar on Klar's behalf. An insurance company taking legal action against a provider is an exceedingly rare occurrence. 

"I got out of law school 42 years ago this May, and I've not seen it before," said Klar's lawyer, Gary Blackburn. "I think it's unusual."

BlueCross argues that $44,000 is far too large a sum to expect for out-of-network care. They offered to pay $9,500, which according to sources, is about 200 percent of what Southern Hills would receive for the same treatment of a Medicare beneficiary. Uninsured patients are frequently written off as bad debt, but because Klar is insured, TriStar is expecting BlueCross to make payment on his behalf.

Non-profit hospitals often have different strategies on the collection of accounts receivable. Outsourcing medical claims management can help get to some of these patients faster, improving the practice's bottom line and reducing bad debt.