An FBI raid always gets attention and Wednesday's raid on Advanced Infusion Systems facitilies in Ridgeland and Chunky were no exception. The Fibbies are as tight-lipped as usual so it will probably be awhile before more is known about the raids. However, two federal court cases might - repeat, might - provide some clues.
Randy Denning sued AIS in Louisiana. The company filled his prescription for medication administered through a pain pump. She discovered in 2021 that "AIS was billing her insurer at a rate of $120 per day for allegedly unauthorized services."
The court fight wound up at the Fifth Circuit Court of Appeals. The Court ruled the unauthorized billings were indeed a breach of contract but Denning lacked standing to sue AIS as she was not the injured party. Case closed.
Blue Cross/Blue Shield and AIS went to war in federal court in Mississippi. AIS sued the insurer for failure to pay claims. Blue Cross counterclaimed, accusing AIS of committing insurance fraud by allegedly including per diem charges for each day medication is administered through a pain pump. However, AIS argued the practice is an industry standard. The two sides skirmished for a while before settling the case and issuing a joint statement:
Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") and the Blue Cross Blue Shield Association ("BCBSA") have evaluated the billings by Bond Pharmacy dba AIS Healthcare ("AIS") that included per diems, and have now concluded, after further evaluation that all of AIS' bills to BCBSMS, including without limitation AIS' bills using HCPCS Code S9328 for per diems, did not constitute fraud, and made no finding of waste or abuse.
AIS, BCBSMS, BCBSA, and Advanced Health Systems, Inc. ("AHS") have settled all disputes arising out of, relating to, or concerning the claims and issues asserted by the parties to the legal proceedings in the lawsuit known as Bond Pharmacy d/b/a Advanced Infusion Solutions v. Advanced Health Systems, Inc. and Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company, United States District Court for the Southern District of Mississippi, Civil Action No. 3:21-cv-123-KHJ-MTP. The settlement includes an arm's length negotiated resolution on mutually acceptable terms by which a confidential amount will be paid to AIS for past services.
There will be a new participation agreement going forward between AIS and BCBSMS that will allow enrollees of the Federal Employee Health Benefits Plan ("FEP") co-administered by BCBSA and its licensee Blue Cross and Blue Shield companies to receive services from AIS as a participating provider for FEP. The settlement does not require an admission of wrongdoing by anyone. The rest of the terms of the settlement are confidential except that (a) AIS can provide this Written Settlement Statement to anyone, and (b) BCBSMS, BCBSA and AHS will and hereby do confirm the authenticity and accuracy of this Settlement Statement. The parties to the confidential settlement agreement have approved this Settlement Statement.
Agreed on October 14, 2022 between Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company, the Blue Cross Blue Shield Association, and Bond Pharmacy dba AIS Healthcare.
U.S. District Judge Kristi Johnson dismissed the case in November.
12 comments:
Mess with the cross and you’ll get the shield
Where there is smoke there is fire-
BC/BS Mississippi knows how to fight long and hard. (e.g. UMMC) They settled this case and apologized because they knew they were wrong. There has to be more to the FBI's involvement than the allegations in this federal lawsuit.
Reminder that the same people who will tell you that cannabis isn’t medicine are always silent about their preferred vices! The don’t mind the “medicines” that Perdue Pharma knew would get America hooked and earn them trillions!
Ahhh…..a “pain clinic patient” is upset
But bam the weed, y’all
I wish the FBI would raid BCBS! They deserve it!
@5:10 pm.
the medical offices filing fraudulent claims should be reported to AG office under anonymous reported.
There are many!
I could give you a few names ..... but I will wait.
Please clarify your proof that BCBS "knew they were wrong and apologized" or concede you're making things up. UMMC was on the ropes if you recall, and still is after losing the burn center.
@7:08 AM The circumstantial evidence is overwhelming. (see e.g. Alex Murtaugh) BC/BS does not give up like this unless they know they're wrong. An apology? Seriously? The apology, in this context, means "We are REALLY GLAD we didn't get popped for punitive damages."
Bill Dees...
The Alex Murtaugh case? Are you serious? There was a whole lot more than circumstantial evidence in that situation. Terrible example Bill.
UMMC cried uncle first because they were hemorrhaging money, and BCBS just let them up so they could get back to business, on BCBS's terms. If they had pursued their litigation of UMMC afterwards, they would have looked like the bad guy you think they are.
As one who uses AIS compounding pharmacy services for the medication in my intrathecal pump. Their charges are absurd! I mean absolutely mind blowingly , astronomical and that’s before BCBS pays a huge portion. Which leaves me over a barrel with a huge payment due because I have no choice in the matter!
AIS has been fraudulently billing insurances for years! Several years ago, I switched to a Humana Medicare plan. AIS and my pain physician had an agreement that intrathecal pump patients receiving their compounded medications from AIS and who had Medicare only,would pay AIS $45 for roughly, a 3 month supply. Medicare does not cover the intrathecal pump meds. But when I switched to Humana, all of a sudden,I started receiving bills for exorbitant amounts i.e.$400+ for the same amount of medications. When I questioned AIS and looked at their billing practices and procedure codes, I realized they were using the code for a home healthcare nurse to come to my home, and administer the medication(s). I was getting my pump refilled in my physician's office and not at home! I complained to Humana, Medicare, Attorney General, etc. because this was insurance fraud, plain and simple! Did I mention I was a retired nurse with 25 yrs of insurance experience?! My complaints fell on deaf ears! Long story short, they billed Humana tens of thousands of dollars and Humana paid! Even after I had spoken with supervisors, managers, etc.! I even filed a complaint with their fraud dept.! Nothing worked! No one listened! To this day, I refuse a Medicare advantage plan because AIS said they will continue to bill in this fashion. They did write off all the monies (my 20%) that they said I owed them! Wonder why? I'd love to have one of those plans again because of the vision and dental benefits and I can't. I can't watch AIS continue to use fraudulent billing practices! I hope the FBI shuts these crooks down! I'll get my pump meds some way, some how. Hopefully from a company nothing like AIS!
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