Horizon Blue Cross Blue Shield and American Specialty Health; Will the NJ Department of Banking and Insurance listen?

Horizon Blue Cross Blue Shield is attacking chiropractors and other professions vital to the health of those who are insured with them.  The proposed but not yet approved relationship with Horizon will have chiropractic, physical therapy, acupuncture and even psychotherapy managed by a company whose sole purpose is to make the difficult job of these helpful and cost-effective providers more difficult while reducing visits and procedures those providers require to do their job properly. Their reward is profits at the expense of providers and their patients when the real driver of healthcare costs is Horizons activities in the marketplace such larger hospital systems resulting from their Omnia plans and drugs.

Many experts have shown that policies such as tiers that are found in Horizon Omnia as well as high deductibles are driving the opioid crisis and the pill economy because those policies reduce access to needed care.   Many hospitals that have gotten much larger due to Omnia, a tiered network introduced a few years ago are now asking for higher reimbursements as they get hit with higher yearly deductibles, many of which are hitting their pocketbooks. For those who are unfamiliar with how deductibles work, a deductible is an amount the patient must pay before their insurance pays anything for the year.  The greatest invention that insurers ever came up with was the yearly deductible.  They process electronic claims and pay nothing until the deductible amount is satisfied.

Primary care physicians as being paid less, while their administrative burdens have increased, resulting in more referrals to high priced specialists that offer little value for a patient’s healthcare dollar.   This approach to healthcare has also increased the number of prescription drugs given, a known problem in the USA since we take more drugs in our country than anywhere else.

Chiropractors who help many people with spinal and chronic pain were 95% tier 2 with  Horizon Omnia, meaning, Horizon made it much more expensive to visit a chiropractor, which was often the least expensive option for effective relief.  Somehow, they figured out to make inexpensive providers cost consumers more, while more expensive services now cost less at hospitals and physicians affiliated with tier 1 hospitals.

Many patients now wait until either their yearly deductible is met or use the money they put into an account designed for health expenses.  This makes patients and their problems more chronic and more costly to treat in a chiropractic office.

Horizon has a history of underpaying chiropractors for years, subjecting them to audits where they recoup fees because the doctor may not have kept adequate notes.

Now, more recently in NJ, Horizon has decided to use American Specialty Health (ASHN), known for reducing payments for doctors, denying medically necessary care both in and out of network which is why they were sued recently for 11.8 million dollars.  Chiropractors were alarmed and many have told their patients what this means.  If your benefits say you are allowed 30 visits, it is unlikely you will be allowed to use them, as we already know from our previous experiences with ASHN and our Cigna patients. This means in or out of network, more costs will be shifted to the patient regardless of the benefits you paid for.

Is it cost-effective to ignore a patient’s health, and then overburden the providers with paperwork, while paying them less and making them fight for the care their patients need for many simple conditions?  Horizon wants chiropractors, physical therapists, acupuncturists, and psychotherapists to find out the hard way, by hiring a company that will pay them less, while they work harder.  A chiropractor’s tier 2 status under Omnia will not change, and they have no incentive to join other than they will be out of network with their EPO plans that have no out of network benefits.  Currently, Horizon has two chiropractors per county in Tier 1, which represents less than 5% of the profession in NJ.

Out of network, doctors will be paid for the first  5 visits in PPO plans, although deductibles are higher than ever, while EPO patients will pay cash to visit these doctors since EPO plans have no out of network benefits.  Horizon will bear no financial responsibility for providers who will not sign the ASHN contract which is merely cost-shifting. Imagine having this insurance and then finding out that the doctor who can finally help you feel better is not covered because they no longer participate in the plan. This cannot be good for anyone who is insured by Horizon, as Edison Township realized when they switched to Cigna a year ago, only to switch back this year to Horizon.  Does Horizon really want to do this when the cost driver is Omnia and the large hospital alliances they forced on us?

ASHN will issue reams of papers in the mail to doctors who bill their PPO plans out of network, as they now do with Cigna, requiring doctors to submit notes to get checks for the work they did months prior.  In network, doctors may be tiered by ASHN if they do the minimum.  Doctors who have practices that rehabilitate their patients or who have chronic cases are out of luck since they will be buried in paperwork.

ASHN was sued for 11.8 million dollars, a recently settled case. Why would Horizon think of partnering with a company that was just fired by Pennsylvania Blue Cross Blue Shield for similar activities?

Chiropractors, physical therapists as well as acupuncturists are being looked upon as being a possible cure for the Opioid crisis.  Why would you make their lives impossible in private practice?   Incidentally, hospital systems are immune to this nonsense.

One more thing we have become aware of is a through complaints board and Yelp websites.  Apparently, Horizon is not well-liked on Yelp either. While I do not necessarily endorse these web sites, When have you ever seen a company get 1 star across the board?  Many of these are patient reviews.

DOBI (Department of Banking and Insurance) approving this will make care more costly, while chiropractic, physical therapy, acupuncture as well as psychotherapy patients have less choice, and treatment becomes less efficient and effective.

This partnership in no way is good for the people chiropractors or other therapists serve; the patients.  The patients will also bear more of the cost, as they will soon realize that the care they really need is no longer available in the network.  They will also find less choice among therapists, physical therapists as well as chiropractors and acupuncturists.  Doctors who now have so many patients with high deductibles which are already a deterrent to care imposed by Horizon are not likely to join.   This simply does nothing for patient access, while paying your healthcare provider less, as ASHN will profit from saying no to medically appropriate care. Since Horizon is not paying anyone until a deductible is reached, these patients are simply insured, cash patients.

Perhaps, DOBI in NJ will understand this, look at the facts and realize that this proposed arrangement with Horizon is bad for NJ, bad for its employees and bad for solving the Opioid crisis.  Unions and patients have already voiced their concerns and the politicians in Trenton are well aware that this time, campaign money from ASHN and Horizon vs. their public is a bad choice to have to make.

Just imagine if you were covered and very few doctors wanted to be in your insurance network, while you paid handsomely for the coverage which is required by law.   Unfortunately, this is what we in NJ are faced with.

A denial by DOBI is a win for the people and will send a strong message that insurance coverage is for the people and should not be a bait and switch with the patient wondering if their visit for their painful problem will be covered and they will be able to afford to visit a quality healthcare provider.  Let DOBI and your legislators know this is not acceptable and you do not want a third party with this type of reputation managing your chiropractic, physical therapy, acupuncture as well as psychotherapy by clicking on this link