Horizon Blue Cross Blue Shield has agreed to pay $100 million to the State of New Jersey as part of a settlement regarding claims the insurer had made false statements prior to winning a contract to manage state’s public worker health plans and then disregarded an accompanying contractual provision.
But after the announcement was made by state Attorney General Matt Platkin during a press conference on Friday, HBCBS fired back with a strong statement that Platkin was mischaracterizing the charges with “over the top” rhetoric for political gain.
“The outgoing Attorney General’s statements continue a disturbing pattern of significantly mischaracterizing and distorting facts to falsely allege intentional wrongdoing where none exists,” Horizon said in a statement on Friday.
“This has never been anything more than a straightforward contract dispute -– one that Horizon tried to resolve in good faith more than four years ago in the same way it has resolved similar disagreements over the course of our long and fruitful partnership with the state: through a negotiated reimbursement.”
The statement continued: “The Attorney General instead chose to waste time and taxpayer resources to achieve the same outcome and now tries to justify his decision to turn a contract dispute into a media circus by hurling loaded, false and dangerous accusations at Horizon for his personal and political benefit.
“This is particularly disappointing as Horizon entered this agreement in the spirit of good faith and partnership that has always defined our relationship with the state. Stripped of the Attorney General’s over-the-top rhetoric, this settlement resolves a contractual dispute concerning how a relatively small number of claims should have been paid.”
During a press conference on Friday, Platkin said Horizon, which administers public plans that insure more than 750,000 state and local government workers and retirees, had ignored a provision in its 2020 contract that required the insurer to charge the state the lesser of the amount billed by a health care provider or an amount negotiated between the provider and Horizon.
But Platkin alleged Horizon was already aware it could not comply with the provision before it bid into the contract and then hid it from state procurement officials.
The Office of the Attorney General said in a statement that Horizon ignored the provisions and submitted more than 1,000 false claims to the state.
“At a time when everyone is rightly concerned about the cost of their health care, it is simply unacceptable that an insurance company would seek to defraud our state and overcharge us while driving up the costs of health care for hundreds of thousands of dedicated public servants,” Platkin said in a statement Friday.
“We will not hesitate to hold accountable anyone who breaks the law and harms our residents, no matter how big or powerful you are. I would like to thank our legal team and the Treasury Department for investigating this case and delivering historic relief for our residents.”
Horizon, in its statement, said it had a different interpretation of the contract than the State of New Jersey and “the settlement makes clear Horizon never retained any portion of monies charged to the state for healthcare provider claims.”
“Horizon paid claims we processed for the state according to the contracts in place with the doctors and hospitals filing those claims,” the insurer said.
Horizon also noted that it had been in discussion with the state since 2021 to resolve the dispute and made “significant financial offers” to address the disputed claims.
“By 2023, we had fully addressed the underlying issues that led to the dispute and in 2024 were again chosen through competitive bid as an administrator of SHBP and SEHBP benefits,” the insurer said.
“To put this settlement in context, during the 4-1/2-year term of the 2020 contract, Horizon processed more than 48 million claims for the state and $20 billion in related payments to providers.
“This settlement involves 0.07% of the claims and 0.46% of the total amount paid to providers.
“During that same period, the steep discounts achieved through Horizon's provider contracts produced $42.6 billion in savings to the SHBP, SEHBP, and its members. Of the $100 million settlement, $93 million covers the difference in claims payments that were in dispute and that Horizon has been seeking to resolve for more than four years.”
