"Slow Pay, Low Pay or No Pay": Blue Cross Approved Surgeries Then Refused to Pay

> But the insurer’s defense went even further, to the very meaning of “prior authorization,” which it had granted women like Arch to pursue surgery. The authorization, they said in court, recognized that a procedure was medically necessary, but it also contained a clause that it was “not a guarantee of payment.” Blue Cross was not obliged to pay the center anything, top executives testified. “Let me be clear: The authorization never says we’re going to pay you,” said Steven Udvarhelyi, who was the CEO for the insurer from 2016 to 2024, in a deposition. “That’s why there’s a disclaimer.

> At the trial, Blue Cross revealed that it had never considered any of the appeals — nor had it ever told the center that they were pointless. “An appeal is not available to review an underpayment,” acknowledged Paula Shepherd, a Blue Cross executive vice president. The insurer simply issued an edict — the payment was correct.

> On several occasions, though, Blue Cross executives had signed special one-time deals with the center, known as single case agreements, to pay for their wives’ cancer treatment.

But at the same time, i guess i'll be contrarian and say the other notable bit to me is that the person wants the absolute best doctors working on her, at the absolute best place possible because they pioneered the technique. I get why. But it's not necessarily reasonable. Obviously, if her cases needs that, she should get it. But it's really unclear from the article - is her case one that any competent surgeon could do, or only these surgeons can do. It does say they pioneered one technique, but that doesn't mean they are the only ones who do it or are good at it. She just says "i want the people who teach other people working on me", which certainly resonates with lots of people (i'm sure that's why it's there), but also, probably too high of a standard?

In the end - the absolute best of everything is expensive. Very expensive. I doubt a system can afford to have that happen for everyone, even if the insurers were not evil fraudsters. So even if we ever fix the insurer side, I think we will also have to fix the patient expectation side around standards of care.