Post At2FqpihtgDE4JazEO by pluralistic@mamot.fr
(DIR) More posts by pluralistic@mamot.fr
(DIR) Post #At2Fp7NnFyV4Gkzmuu by pluralistic@mamot.fr
2025-04-12T18:15:21Z
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A jury has ordered Blue Cross of Louisiana to pay $421m to a hospital specializing in a much sought-after type of breast reconstruction, primarily for cancer survivors. The insurer "preapproved" surgeries for thousands of patients, but then held back 92% of the payments it owed, with CEO Steven Udvarhelyi insisting that "authorization never says we’re going to pay you":https://www.documentcloud.org/documents/25882446-steven-udvarhelyi-deposition/#document/p1/a26309591/
(DIR) Post #At2FpFCOCG8CVhinFg by pluralistic@mamot.fr
2025-04-12T18:15:32Z
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If you'd like an essay-formatted version of this thread to read or share, here's a link to it on pluralistic.net, my surveillance-free, ad-free, tracker-free blog:https://pluralistic.net/2025/04/12/pre-authorization/#is-not-a-guarantee-of-payment2/
(DIR) Post #At2FpMMZYnR6jJXWb2 by pluralistic@mamot.fr
2025-04-12T18:15:56Z
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In a characteristically brilliant and deep investigative story, *Propublica*'s T Christian Miller explains how Blue Cross of Louisiana colluded with other Blue Cross franchises around the country to steal hundreds of millions of dollars by denying claims they'd already approved:https://www.propublica.org/article/blue-cross-blue-shield-louisiana-insurance-lawsuit-breast-cancer-doctors3/
(DIR) Post #At2FpUCaPoCZ2evf8q by pluralistic@mamot.fr
2025-04-12T18:16:09Z
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The hospital at the center of this controversy is the Center for Restorative Breast Surgery in New Orleans, founded by two surgeons, Frank DellaCroce and Scott Sullivan. DellaCroce and Sullivan are pioneers of an advanced form of breast reconstruction called "autologous tissue reconstruction," which eschews implants in favor of the patient's own fat to construct new breasts. 4/
(DIR) Post #At2FpbqC0x2gjWVtLc by pluralistic@mamot.fr
2025-04-12T18:16:23Z
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While other surgeons perform this surgery, DellaCroce and Sullivan are acknowledged as national leaders, having invented many innovative techniques and trained many of the other surgeons who perform the procedure. As a result, patients travel from all over America to the Center for Restorative Breast Surgery.DellaCroce and Sullivan's procedure is extremely precise and labor-intensive, and it comes at a high cost. 5/
(DIR) Post #At2Fpj6kzlS3GvJidc by pluralistic@mamot.fr
2025-04-12T18:16:38Z
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Accordingly, patients seek pre-approval from their insurer before undergoing the procedure, and in Louisiana, that usually means calling up Blue Cross, the state's largest insurer. Despite pre-approving the procedure, Blue Cross of Louisiana has held back over 90% of the payments it owed to the hospital.6/
(DIR) Post #At2Fpsl96y6fCnHbLE by pluralistic@mamot.fr
2025-04-12T18:16:48Z
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Rather than throwing their patients into the Blue Cross meat-grinder, DellaCroce and Sullivan carried the unpaid balance on its books, repeatedly suing Blue Cross for the unpaid amount. Finally, last week, the a jury ordered Blue Cross to pay $421m to the hospital (Blue Cross is appealing).The case dragged Blue Cross's sleazy behavior - normally confined to bureaucratic memos and telephone denials - into the public, and *boy* is it ugly. 7/
(DIR) Post #At2FpzoasY1X5VwxBg by pluralistic@mamot.fr
2025-04-12T18:16:56Z
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Blue Cross's official excuse for denying the claims was that it was acting in the best interest of the millions of Louisianans it insures: *DellaCroce and Sullivan are simply too expensive - it's not realistic for people in an insurance pool to expect that kind of care*. However, Blue Cross executives repeatedly signed one-off, "single case agreements" so that their own wives could get the procedure from DellaCroce and Sullivan.8/
(DIR) Post #At2Fq6iTDiHiUY8f7A by pluralistic@mamot.fr
2025-04-12T18:17:07Z
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In addition to this argument, Blue Cross insisted that the fact that it had pre-approved all of these procedures did not oblige it to pay for them after the fact. Rather, an "approval" is a bureaucratic, heavily disclaimed term of art that means, *maybe we'll pay for this and maybe we won't*. 9/
(DIR) Post #At2FqE9fYzCVYvuyyu by pluralistic@mamot.fr
2025-04-12T18:17:20Z
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In court, however, the company was forced to admit that an "approved" procedure has to be paid for in all but the most exceptional instances, for example, when the patient cancels their insurance between getting approved and going in for surgery.10/
(DIR) Post #At2FqL7Rfea5A3vnzE by pluralistic@mamot.fr
2025-04-12T18:17:31Z
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The insurer also claimed that there were checks and balances to prevent arbitrary claims denials, but then Blue Cross executive VP Paula Shepherd acknowledged that "an appeal is not available to review an underpayment." As Miller writes, "The insurer simply issued an edict — the payment was correct."Meanwhile, Blue Cross didn't just *save* money by denying the claims it had approved - it *made* money. 11/
(DIR) Post #At2FqTMd15TmjT62lM by pluralistic@mamot.fr
2025-04-12T18:17:39Z
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Other Blue Cross organizations in different states would Cross 16% kickbacks to the Louisiana Blue Cross, splitting the take every time it denied a payment.All of this added up to means, motive and opportunity to engage in unbelievably sleazy - and fraudulent - behavior. Overall, Blue Cross paid $43m on $500m worth of invoices from the hospital. In 60% of claims, it paid *nothing*. 12/
(DIR) Post #At2FqadXyaAjHy49bc by pluralistic@mamot.fr
2025-04-12T18:17:49Z
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Blue Cross is one of the nation's largest health insurers, and Blue Cross's argument for stiffing this hospital *is* the argument for letting insurers buy one another up and grow to unimaginable scale. In David Dayen's amazing 2020 book *Monopolized*, he lays out the procession of America's morbid health care monopolization:https://pluralistic.net/2021/01/29/fractal-bullshit/#dayenu13/
(DIR) Post #At2FqiXSb63ZnPHPEG by pluralistic@mamot.fr
2025-04-12T18:18:00Z
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First, we allowed pharma companies to merge to monopoly, which gave them the power to screw hospitals with sky-high drug prices. So the hospitals defensively merged into regional monopolies with the power to negotiate those prices down, but this also gave them the power to overbill insurers. So the insurers *also* merged until they could resist the hospital chains' pricing power and force rates down.14/
(DIR) Post #At2FqpihtgDE4JazEO by pluralistic@mamot.fr
2025-04-12T18:18:11Z
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And indeed, *97%* of doctors and hospitals have a negotiated rate with Blue Cross of Louisiana (remember, it's the state's largest insurer). But DellaCroce and Sullivan haven't joined the Blue Cross network, because the rates the insurer offered wouldn't even cover the costs of the surgeries.The theory that monopolies will defend us from other monopolies is a disastrous example of "the old lady who swallowed a fly" strategy. 15/
(DIR) Post #At2FqwvN6zVCPcZhRY by pluralistic@mamot.fr
2025-04-12T18:18:19Z
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For the strategy to work, *everyone* has to be a monopolist, otherwise they'll get steamrollered - on their wages, their care, or their compensation.And of course, patients don't get to merge to monopoly (that's what governments are for, and we *know* how Blue Cross feels about single payer care). Workers don't get to merge to monopoly either (that's what unions are for, and no one hates a union more than a health care monopolist). 16/
(DIR) Post #At2Fr4l1zJz4hrnYR6 by pluralistic@mamot.fr
2025-04-12T18:18:26Z
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Blue Cross's position - the position of the entire for-profit health industry - is that *they* should be able to grow as large as they can, at the expense of us, the patients. In other words, they are economic tumors - so no wonder they're on the side of breast cancer.17/
(DIR) Post #At2FrCEMCgbLsqZZcO by pluralistic@mamot.fr
2025-04-12T18:18:36Z
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I'm on a 20+ city book tour for my new novel *Picks and Shovels*. Catch me in #PITTSBURGH on May 15 at WHITE WHALE BOOKS:https://whitewhalebookstore.com/events/20250515And in #PDX on Jun 20 at Barnes and Noble:https://stores.barnesandnoble.com/event/9780062183697-0More tour dates here:http://martinhench.comeof/
(DIR) Post #At3MoXxVr6GtF1Kza4 by clusterfcku@mastodon.social
2025-04-12T18:32:36Z
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@pluralistic This is where Luigi has made a difference. These stories never saw the light before. People have suffered, people have died , people have gone bankrupt for the sake of grift and profits in a "rent seeking" type of industry! I don't condone murder, but if the same people who condone atrocities and war crimes in Gaza and elsewhere call it the "fog of War", we can expect that they call his deed to have been comitted in the fog of a war for justice as well.
(DIR) Post #At3MoYsESDdq4vsHzM by wagrimes@sfba.social
2025-04-12T21:22:26Z
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@clusterfcku @pluralistic When the goal of the corporation is to.maximize profits and shareholder dividends at the expense of the customer, the company has lost its way. This seems to be happening more frequently as corporations and equity funds become the primary investors. And as customer abuse increases, so does labor mistreatment as both are increasingly viewed only as sources of profits and not as the most important factors in the reason for being.
(DIR) Post #At3MoZvoWO6JMKYfD6 by MissGayle@urbanists.social
2025-04-13T15:29:33Z
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@wagrimes @clusterfcku @pluralistic Predatory capitalism is eating itself. There are no longer sufficient living wage workers to drive consumption or markets. It's all smoke and mirrors, sleight of hand financialization of the economy. The republicans long for the return of slavery and not having to pay workers anything at all. Who do they think is going to buy or subscribe to their products? Or do they plan to just do away with main street entirely?
(DIR) Post #At3Moao3GjUC4Xvyka by RevXenoFact@dobbs.town
2025-04-13T16:07:57Z
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@MissGayle @wagrimes @clusterfcku @pluralistic you can't give them credit for any plans. These folks are just bank accounts wrapped in human skin.They may end up aiming for such horrors, but note how they can't reverse course to something better for everyone including them.
(DIR) Post #At3VPKjqlpyOaS00um by andrewornot@masto.social
2025-04-13T17:07:58Z
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@clusterfcku @pluralistic