Horizon Blue Cross Blue Shield of New Jersey owes Passaic County $ 8.7 million after insurer fails to stop reimbursing medical providers for off-grid claims, the county alleges in a new trial.
The county says it started capping off-grid costs for around 3,600 employees and retirees in 2015, but Horizon, which runs the county’s self-insurance plan, continued to reimburse costs at older and higher rates. high. The four-count suit was filed April 24 in Paterson State Superior Court.
Horizon, the state’s largest insurer, administered Passaic County health care plans in a “reckless and negligent manner that immediately caused chronic and systemic overpayments to health care providers. outside the network, ”says the complaint.
Matthew Jordan, the chief lawyer for Passaic County, said the county had tried to recoup the “irregular payments” but had been unable to come to an agreement with Horizon.
“The county is confident in the merits of its complaint and looks forward to a favorable ruling on this matter,” Jordan said.
In a statement, Horizon said the facts do not support the Passaic County claims, which Horizon said represent a “relatively small number” of claims.
“We have appreciated our long-standing partnership on behalf of their employees and have always worked to provide excellent service and value that has enabled Passaic County employees to achieve their best health,” the company said.
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Passaic’s complaint is similar to one filed by the Jersey City School District in November, when it alleged that Horizon improperly billed it millions of dollars in off-grid costs and fees. The two sides settled the dispute in March.
Passaic County, like all public entities, has struggled to bring health care costs under control. The county says the amount it pays to provide health benefits has increased by $ 16.7 million since 2017, from $ 13.9 million to $ 30.6 million.
In 2015, the county began making deals with its unions to set a maximum amount it would pay for visits to medical providers outside of Horizon’s network. Off-grid charges have been capped at 150% of the rate paid by Medicare. If an employee saw an off-grid vendor charging more than that, the employee would be charged the difference.
But Passaic County says Horizon continued to pay the highest rates, using county funds, and never charged employees.
Terrence T. McDonald is a reporter for NorthJersey.com. For unlimited access to the most important news from your local community, please subscribe or activate your digital account today.
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