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Specialty pharmacy sues Blue Cross Blue Shield of Wyoming

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Specialty pharmacy sues Blue Cross Blue Shield of Wyoming


A specialty pharmacy that creates customized medicines for sufferers with critical situations is suing Blue Cross Blue Defend of Wyoming for allegedly failing to pay for its providers.

AIS Healthcare, a Mississippi-based pharmacy, filed a lawsuit in U.S. District Courtroom late final month alleging that Blue Cross Blue Defend of Wyoming breached its contract with the corporate and refused to pay tons of of 1000’s of {dollars} for the care it supplied to sufferers.

The specialty pharmacy sued after what its attorneys say has been months of inaction by Blue Cross Blue Defend and after receiving a letter from the medical insurance firm requesting cost for greater than $250,000 it mentioned the pharmacy billed incorrectly.

AIS Healthcare is asking for again pay and a press release from the courtroom that the corporate broke its contract and “unjustly enriched” itself.

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“On the finish of the day, that is all about affected person care,” mentioned Paul Werner, a apply group chief with the worldwide regulation agency Sheppard Mullin, which represents AIS Healthcare. “What the payers are doing and have finished for years now could be actually put AIS within the place of offering care to those sufferers free of charge, which it does as a result of it cares about these sufferers, but it surely’s clearly uneconomical for them to do it.”

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Distinctive well being care

AIS Healthcare specializes within the manufacturing of customized medicines for sufferers reliant on dwelling infusion remedy.

The remedy is reserved for these with debilitating ache and extreme situations, similar to a number of sclerosis, cerebral palsy, spinal wire accidents and most cancers.

Medical doctors surgically implant pumps in sufferers that then carry remedy to their spinal wire.

AIS Healthcare works with medical doctors to create distinctive infusion drugs for every affected person that may repeatedly deal with them for as much as 180 days earlier than they need to be refilled. The pharmacy additionally provides different providers similar to in-patient nurse care and on-call pharmacists for sufferers and medical doctors, in accordance with the lawsuit.

House infusion remedy is a pricey remedy, but in addition one that permits sufferers who in any other case can be in hospitals and long-term care amenities to stay their lives – with out dependence on probably addictive opioids, Werner mentioned.

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Due to the corporate’s specialty, its sufferers quantity within the 1000’s slightly than the tons of of 1000’s throughout the U.S., he mentioned.

Contested compensation

In 2019, Blue Cross Blue Defend of Wyoming contracted with AIS Healthcare so its members might entry the pharmacy’s infusion therapies.

From Might 2019 to April 2022, the medical insurance firm paid AIS Healthcare roughly $370,000 for its providers, courtroom filings present.

However in April of final 12 months, Blue Cross Blue Defend informed AIS Healthcare that it was billing the medical insurance supplier incorrectly and in flip overcharging it.

House infusion suppliers can cost insurance coverage firms a day by day fee “every day a affected person has entry to the infused remedy,” in accordance with the lawsuit. It’s a determine that’s presupposed to have in mind all the prices that go into producing the specialised medicines and the sufferers’ steady use of them.

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AIS Healthcare’s contract with Blue Cross Blue Defend established that the pharmacy can be reimbursed that day by day fee, each a process and value that had been largely dictated by the medical insurance community, Werner mentioned.

“That is not one thing that we got here up with and put to Blue Cross. It is one thing that Blue Cross informed us to do,” he mentioned.

In a sequence of emails, Blue Cross Blue Defend informed the pharmacy that it wasn’t assembly all the necessities to cost that day by day fee.

Blue Cross Blue Defend mentioned that it was already paying AIS Healthcare for the medicine, however as a result of the pharmacy was making the medicines and sending them to physicians however not giving them to sufferers of their properties, the pharmacy couldn’t cost a day by day fee, in accordance with the emails.

Raymond Redd, common counsel for Blue Cross Blue Defend of Wyoming, despatched AIS Healthcare an April 26 letter stating that the pharmacy wanted to repay $251,630, or greater than two-thirds of all the cash it paid the pharmacy for its providers.

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In a press release, Redd and Blue Cross Blue Defend of Wyoming denied the lawsuit’s claims.

“Blue Cross Blue Defend of Wyoming is conscious of the litigation and disputes the allegations made towards it. Nonetheless, as a coverage we don’t touch upon energetic litigation,” Redd mentioned.

Courtroom requests

Since April 2022, AIS Healthcare has continued to deal with sufferers in Wyoming even whereas Blue Cross Blue Defend has refused to pay, Werner mentioned.

AIS Healthcare is asking the courtroom to power Blue Cross Blue Defend of Wyoming to pay greater than $640,000 it says it’s owed for serving the insurance coverage community’s sufferers.

“It isn’t like there’s some miniscule dispute over some minor charges. They don’t seem to be paying us,” Werner mentioned. “We’re offering care. Their sufferers are getting advantages. They’re getting advantages.”

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It is usually requesting a declaration from the corporate acknowledging that AIS Healthcare billed Blue Cross Blue Defend appropriately, that the insurance coverage firm refused to pay and broke its contract, and that it “unjustly enriched” itself by not reimbursing AIS Healthcare.

Werner mentioned the pharmacy wished the acknowledgement to legally reinforce its contract with Blue Cross Blue Defend for future work.

As a part of the courtroom filings, Werner and the authorized staff for AIS Healthcare pointed to the same case the pharmacy introduced towards Blue Cross Blue Defend of Mississippi.

The businesses settled for an undisclosed sum, however as part of that course of each Blue Cross Blue Defend of Mississippi and the Blue Cross Blue Defend Affiliation, which oversees all 34 arms of the medical insurance big, issued a press release that AIS Healthcare’s billing for providers “didn’t represent fraud” and was neither waste nor abuse.

AIS Healthcare itself has confronted questions.

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Investigators from the U.S. Meals and Drug Administration accused the corporate of substandard practices and producing medicine that violated federal regulation in 2017. (The corporate responded by saying not one of the observations rose to the extent of “regulatory significance.”)

Native information in Mississippi additionally reported final month that the FBI raided the corporate.

In a press release to WAPT, an ABC-affiliated information station in Jackson, a spokesperson for the corporate mentioned, “We’re assured that our trade commonplace billing practices are lawful and applicable, and we intend to display that by ongoing cooperation with the federal government.”

Werner mentioned the actions of Blue Cross Blue Defend of Wyoming got here at the price of not solely AIS Healthcare, but in addition susceptible sufferers within the state.

“Can we proceed to take care of these sufferers, or will we minimize them off from crucial care that they want?” he mentioned. “Now we have at all times as an organization opted to take care of sufferers, however we now are within the place of getting to name Blue Cross to activity to step up and meet their contractual obligations and pay for the care that we’re offering to their members.”

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Wyoming

Wondrous Wyoming (1/10/25)

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Wondrous Wyoming (1/10/25)


CASPER, Wyo. — “On Thursday, Jan. 2, 2025 I kayaked into Fremont Canyon at Alcova,” writes photographer Dino Wenino. “The air was still, the sun was shining, the water was like glass and the reflections were beautiful. I didn’t hit ice until 1.7 miles in.”

Do you have a photo that captures the beauty of Wyoming? Submit it by clicking here and filling out the form, and we may share it!

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Wyoming

Winter Storm Bulletins target NE Wyoming and Northern Black Hills

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Winter Storm Bulletins target NE Wyoming and Northern Black Hills


Starting Friday evening, rain and snow will start to move into northeastern Wyoming and southeastern Montana. Winds will begin to pick up out of the NW and gust up to 40-50 MPH. Even if snow accumulations don’t match projections, you only need 1″-2″ of snow to cause major disruptions, given the higher winds.

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Anywhere from Sheridan, Wyoming through Sturgis along I-90 will likely be difficult for travel through at least Sunday afternoon due to blowing snow and icy roads. Anywhere east of Sturgis along I-90 including Rapid City and areas east of Rapid City should see diminished impacts with only an inch or two of snow over the same 48 hour period.

Outside of Lawrence County and perhaps Belle Fourche in South Dakota, most of the state should see manageable conditions, with blowing snow from time to time. However, be ready for snow squalls to quickly change driving conditions even if no winter weather bulletins are active for your area.

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5″-9″ seems reasonable for the northern hills, with localized areas of southwest Lawrence County in the conversation for a foot or more of snow. There will be a sharp cutoff of snow accumulations as you push further east, particularly around Sturgis/Tilford area.

Stay tuned for updates, as our winter storm watches will likely be replaced by winter storm advisories and winter storm warnings in the next 24 hours.

By
NewsCenter1 Weather staff

Our weather department occasionally publishes stories under a byline of “Weather staff.” Most frequently, the “Weather staff” byline is used for straightforward forecasts. At times, this byline is used when a weather story is a collaboration by members of the weather department.





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Wyoming Basketball Teams Suffer Close Losses to New Mexico – SweetwaterNOW

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Wyoming Basketball Teams Suffer Close Losses to New Mexico – SweetwaterNOW






Courtesy photo from gowyo.com

LARAMIE — Both Wyoming basketball teams faced heartbreak against New Mexico, with the Cowboys falling 61-53 in Laramie and the Cowgirls narrowly losing 73-67 in Albuquerque. Despite stellar efforts, the Lobos prevailed in both contests.

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Cowboys’ Defensive Showcase Falls Short

The Wyoming Cowboys held one of the nation’s top offenses to a mere 18 points in the first half, their fourth-lowest opponent total in a half in program history. However, a late rally from New Mexico in the second half sealed the Lobos’ victory at the Arena-Auditorium.

“We were close, and close only counts in horseshoes and hand grenades,” Wyoming head coach Sundance Wicks said. “This game stung a bit. I’m proud of the guys; they executed the game plan and are believing in what we’re doing. The process is showing, but the results aren’t there.”

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The Pokes’ defensive effort limited the Lobos to 33.3 percent shooting for the game, including 23.8 percent from beyond the arc. Offensively, Wyoming struggled, shooting just 32.2 percent overall and 26.3 percent from three-point range.

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Dontaie Allen led Wyoming with 12 points, his third double-digit performance of the season. Cole Henry and Abou Magassa added 10 points each, with Magassa’s career-high also including five rebounds. Jordan Nesbitt contributed eight rebounds and a season-high five assists, while Kobe Newton chipped in nine points on three three-pointers.

Wyoming led 32-18 at halftime, dominating defensively and holding New Mexico scoreless for stretches exceeding four minutes. However, a 12-0 Lobo run early in the second half tightened the game. The Cowboys briefly regained control with an 8-0 run, highlighted by a transition dunk from Nesbitt, but New Mexico surged late. Donovan Dent’s 22 points and Nelly Junior Joseph’s double-double (12 points, 12 rebounds) propelled the Lobos to victory.

Cowgirls Stumble in Fourth Quarter

The Wyoming Cowgirls battled valiantly at The Pit, shooting an impressive 52.1 percent from the field and assisting on 21 of 25 made baskets. However, New Mexico’s strong fourth-quarter performance proved decisive in the Lobos’ 73-67 win.

“We did an excellent job sharing the ball, but turnovers and missed opportunities hurt us,” said Wyoming head coach Heather Ezell.

Allyson Fertig led the Cowgirls with 17 points, followed by Tess Barnes (15) and Malene Pedersen (14), who combined for five three-pointers. Off the bench, McKinley Dickerson added 10 points. Pedersen also tallied a career-high seven assists, while Ola Ustowska contributed a season-best six.

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Wyoming’s unselfish play led to their second 20-plus assist game this season. However, 15 turnovers led to 14 points for New Mexico, and the Lobos held an 8-0 edge in second-chance points.

Despite trailing 37-33 at halftime, the Cowgirls trimmed the deficit to two by the third quarter’s end. A pair of Fertig free throws tied the game at 53-53 early in the fourth, but New Mexico answered with a decisive 7-0 run. Fertig’s three late layups kept Wyoming close, but the Lobos held firm, aided by Hulda Joaquim’s timely three-pointer and a solid team effort.

Looking Ahead

The Cowboys will enjoy a bye weekend before traveling to Boise State for their second matchup in as many weeks. Meanwhile, the Cowgirls return home for back-to-back games, starting with a contest against San Diego State on Saturday at 2 p.m. in the Arena-Auditorium.





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