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

Long read; these bits were notable to me:

> 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 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.

That quote is far less damning when you consider the surrounding context. The reasoning he gave for why "authorization never says we’re going to pay you" is that there might be deductibles, and out of network deductibles might be higher. That seems totally reasonable to me?

[1] https://www.documentcloud.org/documents/25882446-steven-udva...

It’s damning when you read the rest of the article. You’re right about the point of the disclaimer - it was not supposed to secretly mean “lol we have no intention of paying for this ever”, but they used it that way.

> They acknowledged that the disclaimer was not meant as a general excuse to free the company from paying bills. A prior authorization “usually” resulted in a payment, testified Brower, who reviewed the center’s bills. He said that the notice was intended for specific situations. For instance, Blue Cross would not cover a woman who dropped out of her insurance before the operation. Nor would it pay anything if a patient had not met her deductible. But otherwise, Brower said, Blue Cross intended to compensate for a procedure that it had authorized. “It’s inappropriate for us as a company to approve a code and then turn around and deny it,” Brower said.

>it was not supposed to secretly mean “lol we have no intention of paying for this ever”, but they used it that way.

Are you talking about the "Targeted Provider List"? The article says:

>The blocked list meant that each bill from the center received a manual scrub by payment specialists before reimbursement.

That's not the same as “lol we have no intention of paying for this ever”.