Federico A. was involved in a serious car accident and as a result suffered extensive physical injuries. He was transported to the hospital for several emergency surgeries. The hospital promptly submitted his medical bills to his PPO health insurance company, Blue Cross and Blue Shield of Florida, for payment. The treatment had been rendered by a physician who did not participate with Blue Cross as one of its preferred providers (a "non-PPO provider"). Blue Cross denied many of the bills claiming that an assistant surgeon who was utilized in the multiple surgeries was not necessary. Those bills which Blue Cross did pay were significantly reduced to what Blue Cross refers to as its "allowance."
Federico was referred to us by his personal injury attorney for assistance with his substantial medical bills. Based on prior experience, I believe that current version of the Blue Cross Blue Shield of Florida’s PPO policy and the payments made thereunder violate Florida Statutes Sections 627.6044 and 627.6471. Section 627.6044 requires a PPO insurer to specifically identify in the insurance contract the methodology it uses to pay claims. The Blue Cross PPO policy does specifically identify numerous factors which it says will be evaluated in determining the appropriate "allowance." However, in reality, Blue Cross does not utilize any of those factors, and instead relies on only one undisclosed factor. I also believe that the Blue Cross PPO insurance policy violates section 627.6471, by reimbursing non-PPO providers at a rate lower than allowed by law, and by requiring the insureds to pay coinsurance in excess of the statutory maximum.
In addition, after conferring with the treating surgeon, I felt confident that we would be able to prove the necessity of an assistant surgeon for the various procedures.
Based on these factors, I filed suit against Blue Cross for breach of contract. Discovery ensued, but within one week of taking the adjusters’ depositions, Blue Cross agreed to settle the case by paying the doctor’s bills.
As part of the settlement, Blue Cross agreed to reduce its lien against the personal injury proceeds from $270,000 to $10,000. (For more information on reducing and waiving liens, you can search this blog for the word "lien.") Blue Cross also agreed to pay all of my attorneys fees and costs incurred in investigating and prosecuting the case.