A new small business health plan that caps payment for out-of-network ASC services at $2,000 per person per year reduces reimbursements for surgical centers below the minimum level required by New Jersey state law, says the Alliance for Quality Care, a coalition of ASCs and other healthcare providers, which is contesting the state’s recent approval of the plan.
In documents filed on behalf of the Alliance, Roseland, N.J.-based law firm Brach Eichler argues that by capping "payment for out-of-network ASC services at $2,000 per person per calendar year," the new Horizon Advantage Direct Access plan from Horizon Blue Cross Blue Shield of New Jersey "clearly violates" state laws governing small employer plans. The Alliance is urging the state Department of Banking and Insurance (DOBI) to stay its approval of the plan and refer the matter to the Office of Administrative Law for "further fact finding and a hearing to determine the lawfulness of the Commissioner’s actions."
Brach Eichler health law attorney Mark Manigan says actions by insurance companies that attempt to "frustrate providers from going out of network" are a concern because "for your typical non-institutional provider, their only leverage in negotiating in-network contracts is to not participate." If that option’s off the table, "it will undoubtedly have a compressing effect on in-network rates, which is why we are aggressively attempting to defend the out-of-network provider and its existence," says Mr. Manigan.
Brach Eichler filed the application on July 16 and has yet to hear a response from DOBI, which recently underwent a change in leadership. If the new commissioner does not act on the Alliance’s application soon, Mr. Manigan says the firm will bring its request to the Appellate Division before Aug. 1, which is when Horizon is allowed to begin selling the plan to small employers.
—Irene Tsikitas
