Blue Cross accuses North Carolina hospital of overbilling by $76M

The legal battle between a North Carolina hospital and Blue Cross Blue Shield of North Carolina continues after the hospital recently reasserted its claim that the insurer is wrongfully withholding reimbursement for lab tests, 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 acquired the 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, according to the Winston-Salem Journal.

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 the majority 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 LifeBrite has overbilled the insurer by more than $76 million for testing it was not entitled to since August 2017.

6. On May 17, Blue Cross announced it plans to remove LifeBrite Community Hospital of Stokes from in-network status on Aug. 21.

7. On June 7, LifeBrite filed a motion to dismiss Blue Cross' counterclaim, reasserting that the insurer is attempting to get out of paying for the lab tests.

"There are not allegations that the laboratory services at issue were not provided. … It is not a scheme to hide information from the insurance company," states the motion to dismiss.

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