The Louisiana Supreme Court heard oral arguments Sept. 1 on whether to reinstate a $421 million fraud verdict against Blue Cross Blue Shield of Louisiana, Fox8 reported, reviving a yearslong legal fight over the Baton Rouge, La.-based insurer’s payments for out-of-network breast cancer surgeries.
A New Orleans jury issued the original verdict in September 2024, finding Blue Cross liable for fraud in its handling of claims from St. Charles Surgical Hospital and the Center for Restorative Breast Surgery, New Orleans-based providers that specialize in mastectomy and breast reconstruction.
Evidence presented at trial showed Blue Cross paid less than 9% of billed charges on more than 7,800 procedures for 1,680 patients between 2015 and 2023, even after authorizing the surgeries as out-of-network care. An appellate court later overturned the verdict, and the case now sits with the state’s highest court for a final decision on whether to reinstate it.
Scott Sullivan, MD, co-founder of the surgical center, told the publication that the stakes extend beyond the practice’s bottom line.
“The harm is not just for us, but for the patients themselves. There should be a process of appeal, not only for the providers but appeal to protect the patients,” Dr. Sullivan said.
James Williams, the attorney representing the plaintiffs, argued that a reversal would let Blue Cross’ size dictate the outcome.
“My clients are out of all this money that they’ve been defrauded. If they don’t reinstate the jury verdict, then Blue Cross will have used its leverage and size to have won. The fraud will have worked, and my clients are out of the hundreds of millions of dollars and 8,000 claims and thousands of women that they treated believing that Blue Cross would do the right thing,” Mr. Williams said.
Blue Cross has maintained that authorizing a surgery as out-of-network does not guarantee a specific payment amount. After the 2024 verdict, the insurer said it “strongly disagreed” with the outcome and planned to appeal, according to Becker’s prior reporting.
The Louisiana Association of Health Plans has warned that a reinstated verdict could force insurers to pay whatever price out-of-network providers set, potentially raising premiums statewide, a tension the state Supreme Court’s ruling is now expected to help settle.
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