Another critically important lawsuit from lawyer Bob Farley. If insurance companies would provide home nursing care, many children in the MFTD Waiver would not need to rely on Medicaid for nursing care. The state could save millions annually if insurance companies provided home nursing care. Please contact us or Bob Farley directly if you have also been denied nursing through BCBS.
See this article from the Chicago Tribune.
Download or view court filings and documents here.
Attorney Robert H. Farley, Jr., of Naperville, Illinois has filed a Federal lawsuit against Blue Cross and Blue Shield of Illinois to stop the insurance company from terminating twenty-four hour, seven days a week, skilled nursing care to Stephanie, a 23 year old woman in her home. Stephanie is on a ventilator 24 hours pay day and Blue Cross has been paying for 24/7 skilled nursing care since September, 2011. Now, Blue Cross claims that the skilled nursing care being provided to Stephanie is ‘custodial care’ and that she does not need ongoing skilled nursing care. Stephanie’s treating physicians and two independent medical reviews have determined that Stephanie’s care is not custodial and that it is medically necessary for her to have round the clock skilled nursing care. Stephanie will be immediately seeking a Temporary Restraining Order and Preliminary Injunction to stop Blue Cross from terminating her round the clock skilled nursing care.
According to the United States Department of Justice and the State of Illinois, Blue Cross has a long history, in excess of ten (10) years, in the State of Illinois to “wrongly terminate [] insurance coverage for private duty skilled nursing care for medically fragile” persons. The United States Department of Justice - Office of Public Affairs, on February 24, 2011 issued the following statement.
BlueCross BlueShield of Illinois, a division of Health Care Service Corporation has agreed to pay the United States and the state of Illinois $25 million to settle False Claims Act allegations, the Justice Department announced today. The settlement resolves claims made by the United States that BlueCross BlueShield of Illinois wrongly terminated insurance coverage for private duty skilled nursing care for medically fragile, technology dependent children, in order to shift the costs of such care to the Medicaid program. Medicaid funds a special program designed to provide home care for children at risk of institutionalization.
As a result, children whose specialized care should have been covered by BlueCross BlueShield of Illinois under the terms of existing insurance policies, were shifted to the government-funded Home and Community Based Services Medicaid program, . . . As a result, Medicaid spend millions of dollars providing care that should have been paid for by private insurance
The settlement resolves claims that BlueCross BlueShield of Illinois denied patient claims based on internal, undisclosed guidelines that were more restrictive than the language provided to beneficiaries in plan policy materials. Additionally, the government alleged that BlueCross BlueShield of Illinois improperly told policy holders that children were not covered for private duty nursing during the claims review process sought after initial denials.
(See: http://www.justice.gov/opa/pr/2011/February/11-civ-243.html)
The Settlement Agreement further states:
The United States and the State of Illinois contend that they have certain civil claims against BCBS arising from BCBS’s review of BCBS-administered plan beneficiaries’ claims for private duty skilled nursing health insurance benefits whereby BCBS denied such benefits based on BCBS’s determination that such claims were custodial, maintenance, and/or respite care and shifted the costs for such private duty skilled nursing health insurance benefits to Medicaid, and the State of Illinois contends it has civil claims against BCBS for denials that shifted such costs to individual existing and newly eligible beneficiaries, through the following acts and practices during the period from January 1, 2000 through March 16, 2010: (1) fraudulently denying private duty skilled nursing care to eligible beneficiaries needing complex nursing care, using internal home health care guidelines that were more restrictive than the benefit plan language provided to beneficiaries; (2) improperly influencing the outcome of any appeals and external review processes relating to the denials described above.
(emphasis added)
(See http://www.justice.gov/usao/iln/pr/chicago/2011/pr0224_01a.pdf).
Attorney Robert H. Farley, Jr., has been previously appointed by the Federal Court to be Class Counsel in Hampe v. Hamos, to represent medically fragile young adults against the State of Illinois in seeking continuation of skilled nursing services past their 21st birthday. During this litigation against the State of Illinois, Attorney Farley discovered that many families ended up in the State of Illinois program for medically fragile persons as a result of private insurance denying coverage for skilled nursing services. According to Robert Farley, “if the private insurance companies would not improperly deny skilled nursing services for medically fragile persons, then the State of Illinois and the Federal Government would not have to foot the bill to provide skilled nursing services to the medically fragile persons in excess of $60 million dollars per year.”
FOR MORE INFORMATION: Call Attorney Robert H. Farley, Jr., at 630-369-0103.