A major West Coast provider has sued a national health insurer for about $2 million in unpaid medical services.
In a lawsuit filed last week, Palo Alto-based Stanford Health Care alleges that it provided care for six patients between 2018 and 2020 enrolled in a health plan administered by Blue Cross Blue Shield Indiana. The provider’s “usual and customary” charges for the services rendered totaled $2 million.
Indianapolis-based Anthem, as a licensee of the Blue Cross and Blue Shield Association, operates BCBS plans in 14 states, including Indiana.
Per an implied contract between Anthem Blue Cross and Stanford, the provider agreed to render care services to its health plan members, including members of out-of-state affiliates as part of the Blue Card Program, the lawsuit states.
BCBS Indiana is one such out-of-state affiliate and owes Stanford payment for the services, according to the lawsuit. Anthem declined to comment on the litigation.
“Stanford Hospital’s rendering of medically necessary care to the patients was intended to, and did, benefit the patients, and therefore BCBS Indiana,” the lawsuit states.
The contract also includes a discounted rate for the care provided by Stanford, which means BCBS Indiana owed the provider $294,173 of the $2 million in services, the lawsuit claims. The insurer has only paid $78,771.
But, since the contract is implied in fact, it is unclear whether the court will determine that it is legally binding. Such a contract is implied from facts and circumstances that demonstrate a mutual intent to contract and is not necessarily expressed in words, according to the Legal Information Institute.
With regard to this lawsuit, there are two potential scenarios that could play out.
The first is one in which the court finds that the contract is legally enforceable. In this case, Stanford is seeking $215,000 plus interest.
But if the court determines that there is no contractual relationship between Stanford and BCBS Indiana — making the discount void — the provider is asking the insurer to pay the balance of $1.9 million for the patients’ care.
In either scenario, the provider is asking to be reimbursed for all lawsuit-related costs incurred and any other relief the court deems justifiable.
Photo: zimmytws, Getty Images
