Blue Cross Blue Shield Sued By Healthcare Provider Over $300K Insurance Claim

A complaint, originally filed in the Superior Court of New Jersey, was removed to federal court Tuesday. The plaintiff, Premier Orthopaedic Associates of Southern NJ, LLC, brought suit against Anthem Blue Cross Blue Shield and a number of unknown individuals after they allegedly refused to pay the plaintiff for money they were entitled to after they provided services to a patient.

On July 11, 2016, the aforementioned patient allegedly visited Inspira Medical Center, an out-of-network provider. At the Inspira Medical Center, Dr. Rahul Shah performed “medically necessary services, including: aborted cervical decompression and fusion… partial corpectomy… application of local bone, aborted;” among other medically necessary services. Dr. Shah is board-certified and contracted by the plaintiff and performs treatments after obtaining proper authorization from the patient’s provider. In this instance, the complaint explains that a representative for Blue Cross Blue Shield approved the services to be performed by the plaintiff, who contracts both Dr. Shah and Cristian Brenner, who assisted with the services.

Following the completion of the services, the plaintiff billed defendant Blue Cross Blue Shield for the treatments, charges which collectively totaled $301,344.00. The defendants have yet to pay any amount of the balance.

The complaint cites breach of contract, promissory estoppel, and account stated. The plaintiff is seeking a trial by jury, favorable judgment on each count, full payment of $301,344.00, litigation fees, interest, and any other relief deemed proper by the Court.

The plaintiff is represented by Lawall & Mitchell, LLC, while the defendants are represented by Troutman Pepper Hamilton Sanders.