Our good friend Bob Farley has filed another Federal lawsuit, this time targeting
Blue Cross for terminating skilled nursing. Read below for more information.


Attorney Robert H. Farley, Jr., of Naperville, Illinois has filed a Federal lawsuit
against Blue Cross and Blue Shield of Illinois to stop the insurance company from
terminating twenty-four hour, seven days a week, skilled nursing care to Stephanie,
a 23 year old woman in her home.  Stephanie is on a ventilator 24 hours pay day
and Blue Cross has been paying for 24/7 skilled nursing care since September,
2011.  Now, Blue Cross claims that the skilled nursing care being provided to
Stephanie is ‘custodial care’ and that she does not need ongoing skilled nursing
care.  Stephanie’s treating physicians and two independent medical reviews have
determined that Stephanie’s care is not custodial and that it is medically necessary
for her to have round the clock skilled nursing care.  Stephanie will be immediately
seeking a Temporary Restraining Order and Preliminary Injunction to stop Blue
Cross from terminating her round the clock skilled nursing care.

According to the United States Department of Justice and the State of
Illinois, Blue Cross has a long history, in excess of ten (10) years, in the State of
Illinois to “wrongly terminate[] insurance coverage for private duty skilled nursing
care for medically fragile” persons.  The United States Department of Justice –
Office of Public Affairs, on February 24, 2011 issued the following statement.

BlueCross BlueShield of Illinois, a division of Health Care Service Corporation has
agreed to pay the United States and the state of Illinois $25 million to settle False
Claims Act allegations, the Justice Department announced today.  The settlement
resolves claims made by the United States that BlueCross BlueShield of Illinois
wrongly terminated insurance coverage for private duty skilled nursing care for
medically fragile, technology dependent children, in order to shift the costs of
such care to the Medicaid program.  Medicaid funds a special program designed
to provide home care for children at risk of institutionalization.

As a result, children whose specialized care should have been covered by
BlueCross BlueShield of Illinois under the terms of existing insurance policies,
were shifted to the government-funded Home and Community Based Services
Medicaid program, . . . As a result, Medicaid spend millions of dollars providing
care that should have been paid for by private insurance

The settlement resolves claims that BlueCross BlueShield of Illinois denied
patient claims based on internal, undisclosed guidelines that were more
restrictive than the language provided to beneficiaries in plan policy materials.
Additionally, the government alleged that BlueCross BlueShield of Illinois
improperly told policy holders that children were not covered for private duty
nursing during the claims review process sought after initial denials.

( See: http://www.justice.gov/opa/pr/2011/February/11-civ-243.html )

The Settlement Agreement further states:

The United States and the State of Illinois contend that they have certain
civil claims against BCBS arising from BCBS’s review of BCBS-
administered plan beneficiaries’ claims for private duty skilled nursing health
insurance benefits whereby BCBS denied such benefits based on BCBS’s
determination that such claims were custodial, maintenance, and/or respite
care and shifted the costs for such private duty skilled nursing health insurance
benefits to Medicaid, and the State of Illinois contends it has civil claims
against BCBS for denials that shifted such costs to individual existing and
newly eligible beneficiaries, through the following acts and practices during
the period from January 1, 2000 through March 16, 2010: (1) fraudulently
denying private duty skilled nursing care to eligible beneficiaries needing
complex nursing care, using internal home health care guidelines that were
more restrictive than the benefit plan language provided to beneficiaries; (2)
improperly influencing the outcome of any appeals and external review
processes relating to the denials described above.


Attorney Robert H. Farley, Jr., has been previously appointed by the Federal
Court to be Class Counsel in Hampe v. Hamos, to represent medically fragile
young adults against the State of Illinois in seeking continuation of skilled
nursing services past their 21st birthday.  During this litigation against the State
of Illinois, Attorney Farley discovered that many families ended up in the State
of Illinois program for medically fragile persons as a result of private insurance
denying coverage for skilled nursing services.  According to Robert Farley, “if
the private insurance companies would not improperly deny skilled nursing
services for medically fragile persons, then the State of Illinois and the Federal
Government would not have to foot the bill to provide skilled nursing services to
the medically fragile persons in excess of $60 million dollars per year.”

FOR MORE INFORMATION:   Call Attorney Robert H. Farley, Jr., at

Tony Paulauski
Executive Director
The Arc of Illinois
20901 S. LaGrange Rd. Suite 209
Frankfort, IL 60423
815-464-1832 (OFFICE)
815-464-1832 (CELL)