BlueCross BlueShield of Illinois sued over out-of-network charges
(Crain’s) — Two Northwest Side outpatient surgery centers that are part of a group of Chicago-area clinics allege that Blue Cross & Blue Shield of Illinois has reneged on “unambiguous promises” of coverage for services totaling more than $10 million, as the Chicago-based insurer continues to tussle with out-of-network providers.
Both centers are part of American Health Care Centers, which has 14 locations in the Chicago area. The centers offer medical care ranging from primary care to pain management and occupational therapy, according to its website.
In the larger of the two lawsuits, Fullerton Kimball Medical & Surgical Center is seeking to collect $9.9 million in fees for more than 1,100 services rendered from 2007 to 2011, according to a complaint filed June 1 in Cook County Circuit Court. According to records, Fullerton’s president is Dr. Renlin Xia, an anesthesiologist.
In the second case, Western Diversey Surgical Center is seeking to collect $595,000 for more than 110 services given to patients between October 2010 and September 2011, according to a complaint filed the same day in Cook County. Western Diversey’s president is Dr. Jan Barton, an obstetrician/gynecologist.
Fullerton Kimball has never been part of the Blue Cross network, which means it does not have a contract with the insurer that sets rates, that complaint said. For providers, being out of network typically means they haven’t agreed to reduce fees in exchange for a steady stream of Blue Cross patients.
Because it was out of network, Fullerton Kimball, before providing any medical care, verified with Blue Cross that the insurer would pay its fees, the complaint said.
The clinic relied on the verification, opting not to directly bill the Blue Cross members at the time of service, the complaint said. But Blue Cross has refused to pay the claims, the suit alleges.
Under Illinois law, the verification “constitutes Blue Cross’s unambiguous promise to pay the provider for the service,” according to the complaint.
“The whole purpose of calling is to make sure you get paid,” said attorney Dorothy Voss Ward, a partner at Lincolnwood-based law firm Kamensky Rubinstein Hochman & Delott LLP, who has represented doctors in suits against Blue Cross and is not involved in the cases.
Western Diversey makes similar allegations about claims submitted after March 2010, when its network agreement with Blue Cross ended, that complaint said. A representative of Blue Cross, which is part of Chicago-based Health Care Service Corp., declines to comment.
Both surgical centers are represented by John Roberts, a partner in the Chicago office of law firm Edwards Wildman Palmer LLP.
Mr. Roberts, who declined to comment on the new cases, filed a similar suit in 2002 against Blue Cross on behalf of another outpatient surgical center in the Chatham neighborhood on the South Side. In 2010, Blue Cross was ordered to pay $2.9 million in back claims to the center, which is not part of American Health Care Centers.