The Jersey City Board of Education has filed a lawsuit alleging that their insurance provider, Horizon Blue Cross Blue Shield, threatened to eliminate coverage for 14,000 employees the day before Thanksgiving.
By John Heinis/Hudson County View
“JCBOE is seeking immediate restraints to prevent Horizon from ceasing to perform its obligations under the Agreement and from terminating the Agreement,” the complaint, filed in Hudson County Superior Court on Monday, says.
“Without this relief, Horizon’s sharp tactics would cause significant irreparable harm by effectively leaving over 14,000 people without medical coverage and access to medical care during the COVID-19 pandemic and while New Jersey is experiencing a second wave.”
In the suit, the school district claims that they sustained “millions of dollars in losses” since Horizon refused to adjust their out of networks fees for Medicare and Medicaid.
“Horizon also charged hidden fees, including, but not limited to, charges related to CareCoor, Chronic Ped, Episode of Care, Graduate Medical Education Assessment, NES Georgia Statements, Labcorp, ITS fees, and Recovery Fees,” the court filing says.
“In addition, during a conference call with Horizon in early November 2019 to discuss the Hidden Fees, Horizon, for the first time, disclosed that it was charging JCBOE a fee of 25% for repricing out-of-network claims. The Agreement does not state that Horizon is entitled to a 25% fee for repricing OON claims.”
The allegations further state that their agreement didn’t allow Horizon to charge the 25 percent ONN claim fee for repricing ONN claims, which they later revealed was actually closer to 40 percent.
For this reason, the Jersey City BOE has refused to pay the repricing fee, which is now over $1 million dollars.
While Horizon claims they have paid $56,961,171 in out of network claims for the district, they have denied their request to audit the claims, the court filing contends.
In an email from November 17th, Horizon told the BOE that they would terminate service on November 25th if they did not pay outstanding claims totaling $3,359,033.93.
In addition, the amount that Horizon is demanding by November 25, 2020 is grossly overstated as the disputed OON Claim Repricing Fee is only $1,159,844.41,” the suit argues.
“JCBOE has not violated any provisions of the Agreement, and, aside from the fees in dispute, is current with its payments to Horizon.”
The three-count suit is seeking a judgement against Horizon that says the BOE is not on the hook to pay their “repricing and hidden fees,” comply with their audit request, as well to disclose how they calculate their claim reprising fee and what costs are incurred as a result.
Furthermore, the suit also asks for compensatory damages, attorneys’ fees and costs of suit, and any other relief the court deems just and equitable.
Horizon spokesman Thomas Vincz categorically denied the allegations presented in the lawsuit.
“Horizon is always willing to work with our customers who are unable to pay their fees and have, especially during the pandemic, worked with employers throughout the state to help them maintain coverage for their employees,” he said.
“At no time did Horizon ever threaten to terminate the BOE’s coverage and Jersey City Board of Education employees should know that their coverage has remained in place, uninterrupted, while we continue to work with board staff to resolve the issues preventing them from paying the charges owed under their existing contract.”
Editor’s note: This story was updated with a comment from Horizon spokesman Thomas Vincz.
Get Obama care , you claim its so great, now show us.
The district has self-insurance that uses the horizon network to pay claims through a health fund. This is not even considered legally protected under state health insurance laws, but we do have stop gap insurance if the fund runs dry, I hope we are not at that point.