Corporate Compliance

Illinois Blue Cross agrees to pay $25M to settle false claims charges

Compliance Monitor, March 2, 2011

Blue Cross Blue Shield of Illinois will pay the United States and the state of Illinois $25 million to settle civil claims that it wrongly terminated insurance coverage for private duty, skilled nursing care for medically fragile, technologically dependent children, in order to shift them to a Medicaid program, according to a Department of Justice (DOJ) press release.

According to the DOJ, Blue Cross Blue Shield denied patient claims based on guidelines that were more restrictive than the language provided to beneficiaries in plan policy materials. As a result, children whose specialized care should have been covered by Blue Cross and Blue Shield were shifted to the government-funded Home and Community Based Services Medicaid program.

Blue Cross Blue Shield of Illinois will pay $15.5 million to the State of Illinois and $9.5 million to the United States.

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