DES MOINES, Iowa, May 26, 2016 /PRNewswire-USNewswire/ -- St. Gregory Retreat Centers and the Alternative Legal Placement Program (ALPP) announced today that they have filed a lawsuit in federal court accusing Wellmark Blue Cross and Blue Shield of multiple counts of fraud and breach of contract. The lawsuit also accuses specific Wellmark employees of engaging in a scheme to delay and deny millions of dollars in valid insurance claims in an apparent effort to induce the companies into accepting lower reimbursements.
"Wellmark has demonstrated a consistent, organized and egregious pattern of manufacturing excuses to avoid paying valid claims for reimbursement," said Mike Vasquez, St. Gregory founder and chief executive officer. "Wellmark's tactics are both illegal and morally repugnant. We provide life-saving treatment to a high-risk population. However, when Wellmark realized our clients carry higher insurance risks, they tried to use fraud and extortion to avoid paying the valid insurance claims they had preauthorized before we even began treatment."
Wellmark now owes St. Gregory millions of dollars and counting for outstanding insurance claims that the company has delayed or denied on fraudulent bases.
For instance, Wellmark employees conducted post-service reviews, coming up with fraudulent reasons to deny payment for treatment services that Wellmark had already authorized and pre-approved.
In fact, Wellmark conducted a post-service medical necessity review on nearly 100 claims of St. Gregory and ALPP patients – all of which Wellmark had pre-approved as medically necessary, sometimes as many as 5 times during their stay – and now argues that only one of those nearly 100 patients actually needed the treatment that was provided.
"We have tried to resolve this issue with Wellmark, and continue to run into roadblocks," Vasquez said. "Even when they agree they are at fault, they come back to us with new reasons to deny our claims rather than correcting their original mistakes. Their actions are clearly intentional and coordinated, and unfortunately, have left us no choice but to pursue legal action."
St. Gregory provides lifesaving, evidence-based recovery and treatment services to those suffering from drug and alcohol dependence. St. Gregory also oversees the Alternative Legal Placement Program (ALPP), which offers substance abuse treatment for individuals released from the Polk County Jail or transferred from other correctional facilities.
Both St. Gregory and ALPP have tremendous success rates in helping people recover from drug and alcohol dependency. ALPP specifically has also been critical in lowering the population at the Polk County Jail and significantly reducing crime rates after individuals are released from incarceration.
Tom Jackowski, ALPP President / General Counsel
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SOURCE St. Gregory Retreat Centers