$76,000,000 Health Insurance Swindle

A Con Victor Lustig Would  Have Approved

Lab billing jumped more than 22,000 percent from August 2017 to May 2018, from an average of $37,400 per month to about $8.5 million per month………………..

Blue Cross: North Carolina hospital engaged in a ‘$76M health insurance swindle’

The legal battle between a North Carolina hospital and Blue Cross Blue Shield of North Carolina continued with new court filings Aug. 20, according to the Winston-Salem Journal.

Here are seven things to know:

  1. Lilburn, Ga.-based LifeBrite Hospital Management began operating LifeBrite Community Hospital of Stokes in Danbury, N.C., in early 2017 after it acquiredthe facility from Magee, Miss.-based Pioneer Health Services.
  2. In April 2018, LifeBrite sued Blue Cross Blue Shield of North Carolina for allegedly breaching the contract LifeBrite inherited from Pioneer Health Services. LifeBrite claims the insurer is trying to get out of paying at least $15.5 million in laboratory reimbursement payments.
  3. In a counterclaim filed May 16, Blue Cross alleges the hospital is involved in a billing fraud scheme. The insurer claims LifeBrite’s lab billing jumped more than 22,000 percent from August 2017 to May 2018, from an average of $37,400 per month to about $8.5 million per month. “This was done in spite of the fact that LifeBrite knew that the claims it submitted to Blue Cross NC were not payable, were fraudulent, were in violation of the contracts, and were otherwise unlawful,” the insurer’s counterclaim states.
  4. Blue Cross alleges most of the lab tests LifeBrite billed the insurer for were not ordered by LifeBrite providers. “The vast majority of the patients were never present at LifeBrite, were never treated by LifeBrite-credentialed healthcare providers, and were located in areas not serviced by LifeBrite,” the counterclaim states. “Their only connection to LifeBrite was that their urine testing was billed through LifeBrite in order to take advantage of LifeBrite’s participating status and favorable reimbursement rate with Blue Cross NC.”
  5. Blue Cross claims that since August 2017, LifeBrite has overbilledthe insurer by more than $76 million for testing it was not entitled to.
  6. On May 17, Blue Cross announced plans to remove LifeBrite Community Hospital of Stokes from its network. A Blue Cross spokesperson confirmed last week that the hospital is now “out of network for inpatient and/or outpatient care for all lines of business,” according to the Winston-Salem Journal.
  7. LifeBrite is seeking dismissal of Blue Cross’ counterclaim, and the insurer filed a response to the motion to dismiss Aug. 20. The insurer argues the contract between the parties limits LifeBrite’s right to reimbursement to tests performed by the hospital, at the hospital and for hospital patients. Blue Cross contends LifeBrite’s actions represent “a $76 million health insurance swindle” conducted on a national scale, according to the report.

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